study

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? a) Edrophonium b) Carbachol c) Pyridostigmine d) Ambenonium

A) Edrophonium Explanation: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? a) Establish a regular voiding schedule. b) Insert an indwelling urinary catheter. c) Limit fluid intake to 1,000 mL/day. d) Administer prophylactic antibiotics, as prescribed.

A) Establish a regular voiding schedule. Explanation: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking b) Muscle pain, difficulty speaking, headaches, and arthritic changes c) Muscle inflammation, choking when eating, nearsightedness, and painful joints d) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving

A) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking Explanation: With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.

The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation? a) an exaggerated sense of well-being b) slurring of words when excited c) visual hallucinations d) inappropriate laughter

A) an exaggerated sense of well-being Explanation: A client with multiple sclerosis may have a sense of optimism and euphoria, particularly during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of euphoria

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? Administer intradermal injections into each child's inner forearm. Administer intramuscular injections into each child's vastus lateralis. Administer a subcutaneous injection into each child's umbilical area. Administer a subcutaneous injection at a 45-degree angle into each child's deltoid.

Administer intradermal injections into each child's inner forearm.

What basic information will the nurse caring for a patient recently diagnosed with multiple sclerosis (MS) provide to him? A) It is a degenerative disease of the nervous system. B) It usually occurs more frequently in men. C) It has an acute onset. D) It is caused by a bacterial infection.

Ans: A Feedback: Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known; it affects twice as many women as men.

16. When examining a patient with Guillain-Barre' syndrome, the nurse would expect to assess which of the following clinical manifestations? A) Paresthesias of the hands and feet B) Hyperactive deep tendon reflexes C) Hypotension D) Descending weakness

Ans: A Feedback: Sensory symptoms of Guillain-Barre' include paresthesias of the hands and feet, and pain related to the demyelinization of sensory fibers. Other clinical manifestations include hyporeflexia and loss of deep tendon reflexes. A classic feature of Guillain-Barre' is ascending weakness.

14. The nurse would expect to document which of the following in a patient with myasthenia gravis undergoing a Tensilon test? A) Positive Tensilon test B) Negative Tensilon test C) Positive sweat test D) Negative sweat test

Ans: A Feedback: The patient in myasthenic crisis improves immediately following administration of edrophonium chloride (Tensilon). Sweat tests are used in diagnosing cystic fibrosis, not myasthenia gravis.

15. The nurse assessing a patient with multiple sclerosis understands that due to the pathophysiology of this disease process which of the following is the expected primary finding on the MRI? A) Subarachnoid hemorrhage B) Presence of multiple plaques C) Atrophy of the caudate nuclei D) Presence of a tumor

Ans: B Feedback: MRI is the primary diagnostic tool for visualizing plaques, documenting disease activity, and evaluating the effect of treatment. A subarachnoid hemorrhage would be seen on an MRI from a ruptured aneurysm. Atrophy of the caudate nuclei is seen in Huntington's disease. The presence of a tumor indicates brain tumor.

18. A patient with trigeminal neuralgia is taking Tegretol (carbamazepine) to alleviate pain associated with this disorder. It is important to teach the patient that which of the following side effects may occur from taking this medication? A) Skin discoloration B) Drowsiness C) Insomnia D) Tinnitus

Ans: B Feedback: Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia. The patient must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of Tegretol.

A 42-year-old woman diagnosed with metastatic cancer has developed trigeminal neuralgia. She is taking carbamazepine (Tegretol) for pain relief. Which of the following applies to this medication? A) The medication should be taken on an empty stomach. B) Thee patient should be monitored for bone marrow depression.. C) Side effects include renal dysfunction. D) The medication should be taken in maximum dosage form to be effective.

Ans: B Feedback: The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Carbamazepine is taken with meals and should be gradually increased until pain relief is obtained.

3. Which of the following clinical manifestations would alert the nurse caring for a patient with Guillain-Barré syndrome that his status is deteriorating? A) Tidal volume of 500 mL B) Residual lung volume of 1200 mL C) Vital capacity of 11 mL/kg D) Oxygen saturation of 97%

Ans: C Feedback: A vital capacity of 12 to 15 mL/kg in a patient with Guillain-Barre' means that the patient's condition has deteriorated to the point that he may need to be mechanically ventilated. Thus, a vital capacity of 11 mL/kg is a warning. The tidal volume, residual lung volume, and oxygen saturation are within normal values. Breathing in a Guillain Barre' patient would become increasingly labored as the paralysis ascended toward the intercostals and diaphragm.

Which of the following schedules would be most appropriate for the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest

Ans: C Feedback: Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort and improves with rest. The schedule for procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should also be avoided at bedtime.

13. The nurse recognizes that corticosteroid therapy, when used in the treatment of Guillain-Barre' syndrome, reduces the inflammation and edema associated with this neuromuscular disorder. It is most important for the nurse to monitor which of the following lab values for the patient on corticosteroid therapy? A) pH of urine B) Hemoglobin C) Serum potassium D) Serum glucose

Ans: D Feedback: Corticosteroid therapy increases the blood glucose level. Corticosteroids have an effect on insulin and can produce symptoms related to glucose intolerance

8. The nurse is caring for a patient recently diagnosed with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment data would be consistent with the diagnosis of myasthenia gravis? A) Decreased sensation in the hands and feet B) Incoordination of gait C) Facial numbness causing slurred speech D) Generalized weakness of the extremities

Ans: D Feedback: Generalized weakness affects all the extremities and the intercostal muscles, resulting in decreasing vital capacity and respiratory failure in the myasthenia gravis patient. Myasthenia gravis is purely a motor disorder with no effect on sensation or coordination.

Which of the following is a clinical manifestation associated with Guillain-Barré syndrome? A) Vertigo B) Ptosis of the eyelid C) Diminished taste for food D) Vocal paralysis

Ans: D Feedback: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness).

The nurse teaching a patient recently diagnosed with myasthenia gravis should tell him that it is caused by: A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion

Ans: D Feedback: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It isn't a genetic disorder. Combined upper and lower neuron lesions generally occur as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord causes decreased conduction of impulses at an upper motor neuron.

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? a) "My family will take care of me. I've given my daughter durable power of attorney for health care." b) "I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens." c) "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." d) "I know that I'll eventually be unable to make decisions. Signing an advance directive now will save my family grief."

B) "I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens." Explanation: The client requires additional teaching if the client states that he/she will depend on the physician to tell the family what to do in regards to his/her health. The client should not rely on the physician to tell the family what to do. The best way for the client to convey his/her health care wishes is to put them in writing in an advance directive. The client stating that he/she has designated his/her daughter to make health care decisions when the client cannot, that the client has signed an advance directive, or that the client knows an advance directive will help when he/she is unable to make decisions indicate that the client has made decisions about his/her end-of-life care.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: a) fluid overload. b) contractures. c) dry mouth. d) ascites.

B) contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.

Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy? a) reduced emotional stress b) improved functional ability c) better appetite d) increased alertness

B) improved functional ability Explanation: The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? a) weekly visits by another person with MS b) regular exercise c) psychotherapy d) day care for the granddaughter

B) regular exercise Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Crackles in the lung bases Low-pitched rhonchi during expiration Pleural friction rub Sibilant wheezes

Crackles in the lung bases

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should: a) give the client a muscle relaxant. b) have the UAP keep a steady pull on the client to promote forward ambulation. c) assist the UAP with getting the client back in bed. d) explain how to overcome a freezing gait by telling the client to march in place.

D) explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? a) alertness b) appetite c) mood d) muscle rigidity

D) muscle rigidity Explanation: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease

Which goal is the most realistic for a client diagnosed with Parkinson's disease? a) to cure the disease b) to begin preparations for terminal care c) to stop progression of the disease d) to maintain optimal body function

D) to maintain optimal body function Explanation: Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. However, many clients live for years with the disease: and it would not be appropriate to start planning terminal care at this time

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? A. Acute respiratory distress syndrome (ARDS) B. Atelectasis C. Aspiration D. Pulmonary embolism

B. Atelectasis

Because of pre-employment requirements, a female client in her first trimester of pregnancy is requesting a number of vaccines from her primary care provider. What vaccines are approved for her condition? Select all that apply. A. Tetanus, diphtheria, and pertussis vaccine B. Influenza injected vaccine C. Varicella vaccine D. Yellow fever vaccine E. Measles, mumps, and rubella vaccine

A. Tetanus, diphtheria, and pertussis vaccine B. Influenza injected vaccine

A 16-year-old male client comes to the free clinic and is subsequently diagnosed with primary syphilis. What health problem most likely prompted the client to seek care? A. The emergence of a chancre on his penis B. Painful urination C. Signs of a systemic infection D. Unilateral testicular swelling

A. The emergence of a chancre on his penis

An emergency room nurse is assessing a client who is complaining of dyspnea. Which sign would indicate the presence of a pleural effusion? Resonance upon percussion Wheezing upon auscultation Mottled skin seen during inspection Decreased chest wall excursion upon palpation

Decreased chest wall excursion upon palpation

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Nonproductive cough and normal temperature Sore throat and abdominal pain Hemoptysis and dysuria Dyspnea and wheezing

Dyspnea and wheezing

Family members are caring for a client with HIV in the client's home. What should the nurse encourage family members to do to reduce the risk of infection transmission? A. Use caution when shaving the client. B. Use separate dishes for the client and family members. C. Use separate bed linens for the client. D. Disinfect the client's bedclothes regularly.

A. Use caution when shaving the client.

A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? Paradoxical chest movement Cyanosis Hypertension Wheezing

Paradoxical chest movement

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing Cyanosis

Rapid onset of severe dyspnea

A nurse is preparing a presentation for a local high school health class about STIs. When discussing the most commonly reported STIs, which infection would the nurse most likely include? Select all that apply. A. chlamydia B. gonorrhea C. human papillomavirus infection D. herpes simplex 2 virus infection E. syphilis

A. chlamydia B. gonorrhea

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Draining secretions, air, and blood from the thoracic cavity is necessary.

A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client? "Take the medication with milk." "Be sure to wear sunscreen while taking this medicine." "You will not experience GI upset while taking this medication." "Do not drive when taking this medication."

"Be sure to wear sunscreen while taking this medicine." Explanation: Tetracycline may cause a photosensitivity reaction in clients. The nurse should caution the client to use sunscreen when taking this drug. Dairy products can reduce the effectiveness of tetracycline, so the nurse should not advise him or her to take the medication with milk. GI upset is possible with tetracycline administration. Administration of tetracycline does not necessitate driving restrictions. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? "Take a deep breath and then blow short, forceful breaths into the spirometer." "Hold the spirometer at your lips and breathe in and out like you normally would." "When you're ready, blow hard into the spirometer for as long as you can." "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm clear when my chest X-ray is negative." "I'm contagious as long as I have night sweats." "I'll stop being contagious when I have a negative acid-fast bacilli test."

"I'll stop being contagious when I have a negative acid-fast bacilli test."

A client with an H. pylori infection asks why bismuth subsalicylate is prescribed. Which response will the nurse make? "It improves digestion in the stomach." "It aids in the healing of the stomach lining." "It enhances the function of the pyloric sphincter." "It helps propel food from the stomach into the duodenum."

"It aids in the healing of the stomach lining." Explanation: Bismuth subsalicylate suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers. It does not affect digestion, enhance the function of the pyloric sphincter, or propel food from the stomach into the duodenum. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269

A client recovering from the removal of a gastric tumor asks why radiation therapy is needed. Which response will the nurse provide? "It is to heal the wound faster." "It is to kill any remaining cancer cells." "It is to reduce your need for medication." "It is to prevent the development of a wound infection." Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279

"It is to kill any remaining cancer cells." Explanation: Radiation therapy may also be used alone or along with chemotherapy before surgery to decrease the size of the tumor, or after surgery to destroy any remaining cancer cells and to delay or prevent reoccurrence of the cancer. Radiation therapy is not used to heal the surgical wound, reduce the need for medication, or to prevent the development of a wound infection.

A client with a peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen? "My ulcer will heal because these medications will kill the bacteria." "I should take these medications only when I have pain from my ulcer." "The medications will kill the bacteria and stop the acid production." "These medications will coat the ulcer and decrease the acid production in my stomach."

"The medications will kill the bacteria and stop the acid production." Explanation: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton-pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton-pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton-pump inhibitor and bismuth salts (Pepto-Bismol). Research is being conducted to develop a vaccine against H. pylori. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272

A client being treated for a peptic ulcer seeks medical attention for vomiting blood. Which statement indicates to the nurse the reason for the client developing hematemesis? "I think the soda that I drank irritated my stomach." "The pain stopped so I stopped taking the medications." "I felt better but then just got really nauseated and threw up." "I only ate dinner yesterday and it gave me an upset stomach."

"The pain stopped so I stopped taking the medications." Explanation: The client should be instructed to adhere to and complete the medication regimen to ensure complete healing of the peptic ulcer. Because most clients become symptom free within a week, it should be stressed to the client the importance of following the prescribed regimen so that the healing process can continue uninterrupted and the return of symptoms can be prevented. Since the client stopped taking the medication, the ulcer was not healed and became worse. The statements about soda, being nauseated, and eating only one meal would not explain the reason for the client's new onset of hematemesis during treatment for a peptic ulcer. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Influenza vaccine will prevent typical pneumonias." "Viruses like influenza are the most common cause of pneumonia." "Influenza is the major cause of death in the United States." "Getting the flu can complicate pneumonia."

"Viruses like influenza are the most common cause of pneumonia.

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Getting the flu can complicate pneumonia." "Influenza vaccine will prevent typical pneumonias." "Influenza is the major cause of death in the United States." "Viruses like influenza are the most common cause of pneumonia."

"Viruses like influenza are the most common cause of pneumonia."

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed? A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A sectioned portion of the stomach is joined to the jejunum. The antral portion of the stomach is removed and a vagotomy is performed. The vagus nerve is cut and gastric drainage is established.

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278

A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply. Tachycardia Hypotension Mild epigastric pain A rigid, board-like abdomen Diarrhea

A rigid, board-like abdomen Tachycardia Hypotension Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain, which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock. Perforation is a surgical emergency. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction

A. Ineffective tissue perfusion related to bowel ischemia. Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.

A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patients urine output hourly and notifies the physician when the hourly output is less than what? A) 30 mL B) 50 mL C) 100 mL D) 125 mL

A) 30 mL A urine output below 30 mL/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.

The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply. A) Dietary history B) Family history of renal stones C) Medication history D) Surgical history E) Vaccination history

A) Dietary history B) Family history of renal stones C) Medication history Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the patient to stone formation. When caring for a patient with renal stones it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones.

A client on airborne precautions asks the nurse to leave the door open. What is the nurse's best reply? A. "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B. "I'll keep the door open for you, but please try to avoid moving around the room too much." C. "I can open your door if you wear this mask." D. "I can open your door, but I'll have to come back and close it in a few minutes."

A. "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in."

A patient is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what? A) Hydronephrosis B) Nephritic syndrome C) Pyelonephritis D) Nephrotoxicity

A) Hydronephrosis If voiding dysfunction goes undetected and untreated, the upper urinary system may become compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction, causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. This problem does not normally cause nephritic syndrome or pyelonephritis. Nephrotoxicity results from chemical causes.

The nurse and urologist have both been unsuccessful in catheterizing a patient with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the physician using to drain the patients bladder? A) Insertion of a suprapubic catheter B) Scheduling the patient immediately for a prostatectomy C) Application of warm compresses to the perineum to assist with relaxation D) Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours

A) Insertion of suprapubic catheter When the patient cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm.

The nurse has tested the pH of urine from a patients newly created ileal conduit and obtained a result of 6.8. What is the nurses best response to this assessment finding? A) Obtain an order to increase the patients dose of ascorbic acid. B) Administer IV sodium bicarbonate as ordered. C) Encourage the patient to drink at least 500 mL of water and retest in 3 hours. D) Irrigate the ileal conduit with a dilute citric acid solution as ordered.

A) Obtain an order to increase the patients dose of ascorbic acid. Because severe alkaline encrustation can accumulate rapidly around the stoma, the urine pH is kept below 6.5 by administration of ascorbic acid by mouth. An increased pH may suggest a need to increase ascorbic acid dosing. This is not treated by administering bicarbonate or citric acid, nor by increasing fluid intake.

A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence? A) Stress incontinence B) Reflex incontinence C) Overflow incontinence D) Functional incontinence

A) Stress incontinence Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sudden increase in intra-abdominal pressure. Reflex incontinence is loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations usually associated with voiding. Overflow incontinence is an involuntary urine loss associated with overdistension of the bladder. Functional incontinence refers to those instances in which the function of the lower urinary tract is intact, but other factors (outside the urinary system) make it difficult or impossible for the patient to reach the toilet in time for voiding.

The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment finding would suggest that the patient is experiencing retention? A) The patients suprapubic region is dull on percussion. B) The patient is uncharacteristically drowsy. C) The patient claims to void large amounts of urine 2 to 3 times daily. D) The patient takes a beta adrenergic blocker for the treatment of hypertension.

A) The patients suprapubic region is dull on percussion. Dullness on percussion of the suprapubic region is suggestive of urinary retention. Patients retaining urine are typically restless, not drowsy. A patient experiencing retention usually voids frequent, small amounts of urine and the use of beta-blockers is unrelated to urinary retention.

27. A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest? A. Deviation of a great toe laterally B. Abnormal flexion of the great toe C. An exaggerated arch of the foot D. Fusion of the toe joints

ANS: A Rationale: A deformity in which the great toe deviates laterally and there is a marked prominence of the medial aspect of the first metatarsal-phalangeal joint and exostosis is referred to as hallux valgus (bunion). Hallux valgus does not result in abnormal flexion, abnormalities of the arch, or joint fusion. PTS: 1 REF: p. 1121 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

35. A nurse is providing discharge teaching for a client who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend? A. Client's general condition, balance, and weight-bearing prescription B. Client's general condition, strength, and gender C. Client's motivation, age, and weight-bearing prescription D. Client's occupation, motivation, and age

ANS: A Rationale: Assistive devices (e.g., crutches, walker) may be needed. The choice of the devices depends on the client's general condition and balance, and on the weight-bearing prescription. The client's strength, motivation, and weight restrictions are not what the choice of assistive devices is based on. PTS: 1 REF: p. 1122 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

19. A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis? A. Ensuring adequate exposure to sunlight B. Eating a low-purine diet C. Performing cardiovascular exercise while avoiding weight-bearing exercises D. Taking thyroid supplements as prescribed

ANS: A Rationale: Because sunlight is necessary for synthesizing vitamin D, clients should be encouraged to spend some time in the sun. A low-purine diet is not a relevant action, and thyroid supplements do not directly affect bone function. Action must be taken to prevent fractures, but weight-bearing exercise within safe parameters is not necessarily contraindicated. PTS: 1 REF: p. 1140 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

14. The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching? A. Finish the bottle of nasal spray to clear the infection effectively. B. Nasal spray can only be shared between immediate family members. C. Nasal spray should be given in a prone position. D. Overuse of nasal spray may cause rebound congestion.

ANS: D Rationale: The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximal distribution of the spray. Only the client should use the bottle. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

An expected nursing intervention for a patient diagnosed with Bell's palsy would be which of the following? A) Applying a protective eye shield B) Encouraging the patient to eat on the affected side C) Avoiding analgesics D) Avoiding brushing of the teeth

Ans: A Feedback: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The patient is encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to provide self-care including oral hygiene.

5. When developing a plan of care for a patient with Guillain-Barre' syndrome, the nurse knows that which of the following nursing interventions would receive priority? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Assisting the patient with activities of daily living D) Determining abnormalities of cognitive function

Ans: A Feedback: Impaired gas exchange would be the priority. Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions aimed at enhancing physical mobility and preventing a deep vein thrombosis are utilized. Assisting the patient with activities of daily living is important but would not be the priority nursing intervention. Guillain-Barre' does not affect cognitive function or level of consciousness.

The nurse would expect to find which of the following symptoms when assessing a 38-year-old patient diagnosed with multiple sclerosis? A) Vision changes B) Absent deep tendon reflexes C) Tremors at rest D) Flaccid muscles

Ans: A Feedback: Vision changes, such as diplopia, nystagmus, and blurred vision are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive, not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in patients with multiple sclerosis. Affected muscles are spastic rather than flaccid.

2. The nurse teaching a patient with trigeminal neuralgia about factors that precipitate an attack would be correct in teaching him to avoid: A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking liquids at room temperature

Ans: A Feedback: Washing the face should be avoided if possible due to the fact that this activity can trigger an attack of pain in a patient with trigeminal neuralgia. Exposing the skin to sunlight is not harmful to this patient. Using artificial tears and drinking liquids at room temperature are appropriate behaviors.

28. Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A) Peritonitis B) Gastritis C) Gastroesophageal reflux D) Acute pancreatitis

Ans: A Feedback: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.

17. A patient with Guillain-Barre' has had arterial blood gases (ABGs) drawn. Which of the following ABG values indicates that the patient's status is deteriorating? A) pH 7.37 B) PaCO2 60 C) HCO3 24 D) Oxygen saturation of 94%

Ans: B Feedback: A PaCO2 of 60 places the patient with Guillain-Barre' in an acidotic state due to hypoventilation from respiratory muscle weakness. The pH, HCO3, and oxygen saturation are within normal levels.

7. The physician has ordered a Tensilon test to rule out myasthenia gravis. The nurse knows that which of the following medications would be used to counteract the side effects of the Tensilon? A) Baclofen (Lioresal) B) Atropine (AtroPen) C) Epinephrine (Adrenalin) D) Narcan (Naloxone)

Ans: B Feedback: Atropine 0.4 mg controls the side effects of Tensilon, which include bradycardia, sweating, and cramping. Baclofen is a skeletal muscle relaxant used in the treatment of multiple sclerosis. Epinephrine is used in the treatment of anaphylaxis, cardiac arrest, and bronchospasm. Narcan is used to reverse the narcotic-induced respiratory depression.

6. Upon admission, the physician orders baclofen (Lioresal) for a patient diagnosed with multiple sclerosis. The nurse knows that which of the following is an expected outcome of this medication? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Limited severity and duration of exacerbations

Ans: B Feedback: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Anticholinesterase agents increase muscle strength in the upper extremities. Corticosteroids limit the severity and duration of exacerbations.

Bell's palsy is a disorder of cranial nerve VII. What are the clinical manifestations of the disorder? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia

Ans: B Feedback: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis.

10. It is important to frequently monitor the patient with Guillain-Barre' syndrome when ascending paralysis is occurring. When assessing the patient for bulbar muscle weakness, the nurse should be alert to which of the following clinical manifestations? A) Decreased level of consciousness B) Inability to clear secretions C) Hypersensitivity of hands and feet D) Increased intracranial pressure

Ans: B Feedback: Bulbar muscle weakness related to demyelinization of the glossopharyngeal and vagus nerves results in an inability to swallow or clear secretions. Guillain-Barre' does not affect cognitive function or level of consciousness. Sensory symptoms include paresthesias of the hands and feet related to demyelinization of the sensory fibers. Guillain-Barre' does not cause increased intracranial pressure.

1. A nurse caring for a patient with possible bacterial meningitis in the ICU knows that which of the following assessment findings would be expected for a patient with bacterial meningitis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

Ans: B Feedback: Clinical manifestations of bacterial meningitis include positive Brudzinski's sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski's sign. Positive Homan's sign (pain upon dorsiflexion of the foot) and negative Romberg's sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities and is not an initial assessment to rule out bacterial meningitis.

When teaching the patient with multiple sclerosis how to reduce fatigue, the nurse should tell him to: A) Take a hot bath. B) Rest in an air-conditioned room. C) Increase the dose of muscle relaxants. D) Avoid naps during the day.

Ans: B Feedback: Fatigue is a common symptom in patients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the patient with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

1. A nurse is caring for a patient who has just been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? A) Inflammation of the lining of the stomach B) Erosion of the lining of the stomach or intestine C) Bleeding from the mucosa in the stomach D) Viral invasion of the stomach wall

Ans: B Feedback: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.

27. A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A) The patient has abdominal bloating that developed rapidly. B) The patient has a rigid, "boardlike" abdomen that is tender. C) The patient is experiencing intense lower right quadrant pain. D) The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.

Ans: B Feedback: An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.

26. A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A) Administration of antiemetics B) Insertion of an NG tube for decompression C) Infusion of hypotonic IV solution D) Administration of proton pump inhibitors as ordered

Ans: B Feedback: In treating the patient with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration.

33. A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery? A) Disturbed Body Image Related to Obesity B) Deficient Knowledge Related to Risks and Expectations of Surgery C) Anxiety Related to Surgery D) Chronic Low Self-Esteem Related to Obesity

Ans: B Feedback: It is expected that patients seeking bariatric surgery may have challenges with body image and self-esteem related to their obesity. Anxiety is also expected when facing surgery. However, if the patient's knowledge remains deficient regarding the risks and realistic expectations for surgery, this may show that the patient is not an appropriate surgical candidate.

A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, revealed during the history and physical assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Ans: C Feedback: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS.

11. The nurse knows that plasmapheresis is being utilized in the treatment of the patient with Guillain-Barre' syndrome for which of the following reasons? A) Removal of anti-acetylcholine receptor antibodies B) Reduction in the number of bacteria in the bloodstream C) Decrease in antibodies attacking peripheral nerve myelin D) Removal of potassium and fluid

Ans: C Chapter: 64 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Patient Needs: A-1 Feedback: Plasmapheresis and IV immunoglobulin (IVIG) are used to directly affect the peripheral nerve myelin antibody level. Both therapies decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on mechanical ventilation. In myasthenia gravis, plasmapheresis is used to remove anti-acetylcholine receptor antibodies. Antibiotics reduce the number of bacteria in the bloodstream. Hemodialysis removes fluid and potassium.

21. A nurse is providing anticipatory guidance to a patient who is preparing for bariatric surgery. The nurse learns that the patient is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the patient's anxiety? A) Emphasize the fact that bariatric surgery has a low risk of complications. B) Encourage the patient to focus on the benefits of the surgery. C) Facilitate the patient's contact with a support group. D) Obtain an order for a PRN benzodiazepine.

Ans: C Feedback: Support groups can be highly beneficial in relieving preoperative and postoperative anxiety and in promoting healthy coping. This is preferable to antianxiety medications. Downplaying the risks of surgery or focusing solely on the benefits is a simplistic and patronizing approach.

15. A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurse's best action? A) Insert a nasogastric tube promptly. B) Reposition the patient supine. C) Monitor the patient closely for further signs of dumping syndrome. D) Assess the patient for signs and symptoms of aspiration.

Ans: C Feedback: The patient's symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the patient's symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the patient's surgery.

24. A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care? A) Hematemesis and persistent sensation of fullness B) Abdominal bloating and recurrent constipation C) Intermittent pain and bloody stool D) Unexplained bowel incontinence and fatty stools

Ans: C Feedback: When the patient is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors.

9. The nurse is caring for a recently diagnosed patient with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment parameter should the nurse complete to confirm the diagnosis of myasthenia gravis? A) Passive range of motion of the neck B) Check of deep tendon reflexes C) Application of painful stimuli to legs D) Visual screening using the Snellen chart

Ans: D Feedback: Patients with myasthenia gravis commonly exhibit diplopia (double vision) and ptosis. Using the Snellen chart enables the nurse to assess both of these clinical manifestations. Performing passive range of motion on the neck indicates whether or not the patient has nuchal rigidity, which is a clinical manifestation of meningitis, not myasthenia gravis. Checking deep tendon reflexes is not specific to myasthenia gravis. Application of painful stimuli assesses level of consciousness but also is not specific to myasthenia gravis.

Which of the following primary manifestations is the nurse most likely to assess in a patient diagnosed with MS? A) Dementia B) Bradykinesia C) Contracture deformities D) Difficulty in coordination

Ans: D Feedback: The primary symptoms most commonly reported with patients who have MS are difficulties with coordination, spasticity of the extremities, and loss of coordination. Secondary symptoms of MS include contracture deformities and rarely dementia.

A client comes to the clinic for an evaluation. During the visit, the client reports a fever, malaise, hair loss, and weight loss. Further assessment reveals lymphadenopathy. The client also reports a penile ulcer that appeared about 4 weeks ago but went away. The nurse suspects the client may have syphilis and interprets the client's assessment findings as suggestive of which stage of this disease? A. primary B. secondary C. latent D. tertiary

B. secondary

The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day? A) 1,250 mL B) 2,000 mL C) 2,750 mL D) 3,500 mL

B) 2,000 mL Unless contraindicated by renal failure or hydronephrosis, patients with renal stones should drink at least eight 8-ounce glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding 2 L a day is advisable.

The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? A) Provide medication teaching related to pseudoephedrine sulfate. B) Teach the patient to perform pelvic floor muscle exercises. C) Prepare the patient for an anterior vaginal repair procedure. D) Provide information on periurethral bulking.

B) Teach the patient to perform pelvic floor muscle exercises. Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions has a behavioral approach.

The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite? A) Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group. C) Men of all ages are less prone to UTIs, but typically experience more severe symptoms. D) The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.

B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group. The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging. The prevalence of infection in men older than 50 years of age approaches that of women in the same age group. Men are not more likely to be asymptomatic and are not known to be reluctant to report UTIs.

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the client supine and insert an NG tube. D. Page the primary provider and report that the client may be obstructed.

B. Contact the primary care provider promptly and report these signs of perforation. Rationale: The client's change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured. B. Document these expected assessment findings. C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine

B. Document these expected assessment findings. Rationale: Redness and slight bleeding are expected, so no further intervention or assessment is likely necessary.

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

B. Insertion of a nasogastric tube Rationale: Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.

A client has a concentration of S. aureus located on the skin. The client is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A. Infection B. Colonization C. Disease D. Bacteremia

B. Colonization

A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment? A) Clearly explain the potential benefits of pelvic floor muscle exercises. B) Ensure the patient knows that surgery will be required if the exercises are unsuccessful. C) Arrange for biofeedback when the patient is learning to perform the exercises. D) Contact the patient weekly to ensure that she is performing the exercises consistently.

C) Arrange for biofeedback when the patient is learning to perform the exercises. Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise (PME) uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. This objective assessment is likely superior to weekly contact with the patient. Surgery is not necessarily indicated if behavioral techniques are unsuccessful.

The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurses assessment reveals that the stoma is a dark purplish color. What is the nurses most appropriate response? A) Document the presence of a healthy stoma. B) Assess the patient for further signs and symptoms of infection. C) Inform the primary care provider that the vascular supply may be compromised. D) Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.

C) Inform the primary care provider that the vascular supply may be compromised. A healthy stoma is pink or red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma.

An immunosuppressed client is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family? A. Family members should avoid receiving vaccinations until the client has recovered from his or her illness. B. Wipe down hard surfaces with a dilute bleach solution once per day. C. Maintain cleanliness in the home, but recognize that the home does not need to be sterile. D. Avoid physical contact with the client unless absolutely necessary.

C. Maintain cleanliness in the home, but recognize that the home does not need to be sterile.

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? Correct use of a ventilator Correct use of incentive spirometry Correct technique for rhythmic breathing Correct use of a mini-nebulizer

Correct use of incentive spirometry

Which ulcer is associated with extensive burn injury? Cushing ulcer Curling ulcer Peptic ulcer Duodenal ulcer

Curling ulcer Explanation: Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272

A client sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this client? Curling's ulcer Peptic ulcer Esophageal ulcer Meckel's ulcer

Curling's ulcer Explanation: Curling's ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum. Peptic, esophageal, and Meckel's ulcers are not related to burn injuries. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272

The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices? A) Empty the collection bag when it is between one-half and two-thirds full. B) Limit fluid intake to prevent production of large volumes of dilute urine. C) Reinforce the appliance with tape if small leaks are detected. D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area

D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area The patient is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should not be allowed to become more than one-third full.

An older adult has experienced a new onset of urinary incontinence and family members identify this problem as being unprecedented. When assessing the patient for factors that may have contributed to incontinence, the nurse should prioritize what assessment? A) Reviewing the patients 24-hour food recall for changes in diet B) Assessing for recent contact with individuals who have UTIs C) Assessing for changes in the patients level of psychosocial stress D) Reviewing the patients medication administration record for recent changes

D) Reviewing the patients medication administration record for recent changes Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. Stress and dietary changes could potentially affect the patients continence, but medications are more frequently causative of incontinence. UTIs can cause incontinence, but these infections do not result from contact with infected individuals.

A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply. A) Food cravings B) Upper abdominal pain C) Insatiable thirst D) Uncharacteristic fatigue E) New onset of confusion

D) Uncharacteristic fatigue The most common subjective presenting symptom of UTI in older adults is generalized fatigue. The most common objective finding is a change in cognitive functioning. Food cravings, increased thirst, and upper abdominal pain necessitate further assessment and intervention, but none is directly suggestive of a UTI.

The primary nursing goal for a client with myasthenia gravis is to: a) provide psychological support and reassurance. b) promote comfort and relieve pain. c) ensure a safe environment. d) maintain respiratory function.

D) maintain respiratory function. Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.

A client has presented at the ED with copious diarrhea and accompanying signs of dehydration. During the client's health history, the nurse learns that the client recently ate oysters from the Gulf of Mexico. The nurse should recognize the need to have the client's stool cultured for microorganisms associated with what disease? A. Ebola B. West Nile virus C. Legionnaire disease D. Cholera

D. Cholera

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. Inform the physician promptly that there is in imminent leak in the drainage system. Encourage the client to do deep breathing and coughing exercises. Document that the chest drainage system is operating as it is intended.

Document that the chest drainage system is operating as it is intended.

Sudden onset of lung impairment in a client who had normal lung function The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? Elevated troponin levels Elevated white blood count Elevated myoglobin levels Elevated B-type natriuretic peptide (BNP) levels

Elevated troponin levels

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? Hematemesis Bradycardia Hypertension Polyuria

Hematemesis The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1270

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Water-seal chest drainage set-up Manual resuscitation bag Oxygen analyzer

Manual resuscitation bag

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? Percuss the client's lungs and thorax. Have the client perform incentive spirometry. Measure the client's oxygen saturation. Determine whether the client can now perform forced expiratory technique (FET).

Measure the client's oxygen saturation.

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following? Mental confusion Bradycardia Bradypnea Hypertension TAKE ANOTHER QUIZ

Mental confusion Explanation: Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1276

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) pH Bicarbonate (HCO3-)

Partial pressure of arterial oxygen (PaO2)

Which of the following manifestations are associated with a deficiency of vitamin B12? Select all that apply. Pernicious anemia Macrocytic anemia Thrombocytopenia Loss of hair Lethargy

Pernicious anemia Macrocytic anemia Thrombocytopenia Decreased vitamin B12 can result in pernicious anemia, macrocytic anemia, and thrombocytopenia. Decreased iron can result in lethargy and loss of hair. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1268

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? Place the end of the chest tube in a container of sterile saline. Apply an occlusive dressing and notify the physician. Clamp the chest tube immediately. Secure the chest tube with tape.

Place the end of the chest tube in a container of sterile saline.

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? Shortness of breath Weight loss Fever Headache

Shortness of breath

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? Three meals and 120 ml fluid daily Three meals and three snacks and 120 mL fluid daily Six small meals and 120 mL fluid daily Six small meals daily with 120 mL fluid between meals

Six small meals daily with 120 mL fluid between meals Explanation: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator. Check for an apical pulse. Suction the client's artificial airway.

Suction the client's artificial airway.

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Ensure adequate potassium intake during therapy Blood levels will be evaluated after 1 week Take the medication at bedtime to accommodate sedative effects Take the medication 2 hours before or after other medications

Take the medication 2 hours before or after other medications Explanation: Sucralfate should be taken at least 2 hours before or after other medications. It does not decrease potassium levels and laboratory follow up is unnecessary. Sucralfate does not cause sedation. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is hypoxic from suctioning. The patient is having a stress reaction. The patient is having a myocardial infarction. The patient is in a hypermetabolic state.

The patient is hypoxic from suctioning.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Absence of bloody drainage in the anterior/upper tube Skin around tube is pink. Bloody drainage is observed in the collection chamber. The tissues give a crackling sensation when palpated.

The tissues give a crackling sensation when palpated.

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? a) Increased ability to sleep b) Relief from pain c) Relief from constipation d) Reduced muscle spasticity

d) Reduced muscle spasticity Dantrolene reduces muscle spacticity. It doesn't increase the ability to sleep or relieve constipation or pain.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.46, PaO2 80 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg

pH 7.28, PaO2 50 mm Hg

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has? peptic ulcer disease ulcerative colitis appendicitis diverticulitis

peptic ulcer disease Explanation: Peptic ulcer disease is characterized by dull, gnawing pain in the midepigastrium or the back that worsens with eating. Ulcerative colitis is characterized by exacerbations and remissions of severe bloody diarrhea. Appendicitis is characterized by epigastric or umbilical pain along with nausea, vomiting, and low-grade fever. Pain caused by diverticulitis is in the left lower quadrant and has a moderate onset. It's accompanied by nausea, vomiting, fever, and chills.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. pneumothorax. hemothorax. consolidation.

pleural effusion.

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? Fit all employees with protective masks. Insist on adequate breaks for each employee. Give workshops on disease prevention. Provide employees with smoking cessation materials.

Fit all employees with protective masks.

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? A client exhibits symptoms of dyspnea. A client has a respiratory rate of 10 breaths per minute. A client requires permanent ventilation. A client has respiratory acidosis.

A client requires permanent ventilation.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for A kink in the ventilator tubing A cut or slice in the tubing from the ventilator Higher than normal endotracheal cuff pressure Malfunction of the alarm button

A kink in the ventilator tubing

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A 92-year-old resident who needs extensive help with ADLs A resident who suffered a severe stroke several weeks ago A resident with mid-stage Alzheimer disease A resident with severe and deforming rheumatoid arthritis

A resident who suffered a severe stroke several weeks ago

What dietary recommendations should a nurse provide a client with a lung abscess? A. A diet low in calories B. A diet rich in protein C. A carbohydrate-dense diet D. A diet with limited fat

B. A diet rich in protein

Which is a potential complication of a low pressure in the endotracheal tube cuff? A. Tracheal bleeding B. Aspiration pneumonia C. Tracheal ischemia D. Pressure necrosis

B. Aspiration pneumonia

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? Blood-tinged sputum Bradypnea Respiratory alkalosis Productive cough

Blood-tinged sputum

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis? a) Imbalanced nutrition: less than body requirements b) Impaired urinary elimination c) Ineffective airway clearance d) Risk for injury

C) Ineffective airway clearance Explanation: In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C. The system has an air leak.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? Heart rate, 112 bpm Moderate amounts of colorless sputum Pain of 5 on a 1-to-10 scale Chest tube drainage, 190 mL/hr

Chest tube drainage, 190 mL/hr

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Changes the setting on the ventilator to increase breaths to 14 per minute Consults with the physician about removing the client from the ventilator Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning

Continues assessing the client's respiratory status frequently

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis? a) Increased weakness. b) Diaphoresis. c) Increased salivation. d) Improved muscle strength after I.V. administration of edrophonium chloride.

D) Improved muscle strength after I.V. administration of edrophonium chloride. Explanation: Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote more efficient and controlled ventilation and to decrease the work of breathing Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote the strengthening of the client's diaphragm Promote the client's ability to take in oxygen

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery

Intubate the client and control breathing with mechanical ventilation

The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? Pulmonary function studies Exercise tolerance tests Arterial blood gas values Chest x-ray

Pulmonary function studies

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Mobilizing early Using incentive spirometry Receiving vaccinations Using prescribed opioids

Receiving vaccinations

The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? Resumption of the client's ADLs The family's willingness to care for the client Nutritional status and fluid balance Signs and symptoms of respiratory complications

Signs and symptoms of respiratory complications

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator.

Suction the client's artificial airway.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? Cough Hemoptysis Syncope Tachypnea

Tachypnea

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse? The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room. The employee doesn't remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room. The employee removes all personal protective equipment and washes his hands before leaving the client's room. The employee enters the room wearing a gown, gloves, and a mask.

The employee enters the room wearing a gown, gloves, and a mask.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? To remove air from the pleural space To drain copious sputum secretions To monitor bleeding around the lungs To assist with mechanical ventilation

To remove air from the pleural space

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? Turn onto the affected side. Use a prescribed analgesic. Avoid using a pillow while splinting. Use a heat or cold application.

Turn onto the affected side.

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) limiting fluid intake to 1,000 mL/day b) setting a regular time for elimination c) using an elevated toilet seat d) eating a diet high in fiber

A) imiting fluid intake to 1,000 mL/day Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position

Which is an initial sign of Parkinson's disease? a) tremor b) bradykinesia c) rigidity d) akinesia

A) tremor Explanation: The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Aspiration pneumonia Tracheal bleeding Tracheal ischemia Pressure necrosis

Aspiration pneumonia

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse should ... Sets a schedule to suction the tracheostomy every hour Assesses the client's tracheostomy and lung sounds every 15 minutes Decreases the amount of humidity set to flow through the tracheostomy tube Encourages the client to cough every 30 minutes and prn

Assesses the client's tracheostomy and lung sounds every 15 minutes

When teaching a client about levodopa-carbidopa therapy for Parkinson's disease, a nurse should include which instruction? a) "Report any eye spasms." b) "Be aware that your urine may appear darker than usual." c) "Stop taking this drug when your symptoms disappear." d) "Take this medication at bedtime."

B) "Be aware that your urine may appear darker than usual." Explanation: Levodopa-carbidopa, used to replace insufficient dopamine in the client with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life

Which intervention does a nurse implement for clients with empyema? Institute droplet precautions Place suspected clients together Encourage breathing exercises Do not allow visitors with respiratory infections

Encourage breathing exercises

The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply. A. Progressive weakening of human immune systems B. Use of extended-spectrum antibiotics C. Population movements D. Increased global travel E. Globalization of food supplies

B. Use of extended-spectrum antibiotics C. Population movements D. Increased global travel E. Globalization of food supplies

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." "It is a hereditary disease." "It is probably your nerves."

"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1267

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? "The mucus-secreting glands are abnormal." "There are fibrous cysts in the lungs." "Allergic reactions cause inflammation in the lungs." "Early treatment can stop the progression of the disease."

"The mucus-secreting glands are abnormal."

A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups? A. Preschool-aged children B. Adults with diabetes and/or kidney disease C. Older adults with compromised health status D. Infants under the age of 12 months

C. Older adults with compromised health status

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstruction C. History of diverticulitis D. Longstanding psychosocial stress

A. High levels of alcohol consumption. Rationale: Risk factors include high alcohol intake; cigarette smoking; and high-fat, high-protein, low-fiber diet. Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer.

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed? A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A sectioned portion of the stomach is joined to the jejunum. The antral portion of the stomach is removed and a vagotomy is performed. The vagus nerve is cut and gastric drainage is established.

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. Explanation: A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level

D. Potassium level Rationale: In elderly clients, it is important to monitor the client's serum electrolyte levels closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and hemoglobin levels

The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patients health education, what nutritional guidelines should the nurse provide? A) Restrict protein intake as ordered. B) Increase intake of potassium-rich foods. C) Follow a low-calcium diet. D) Encourage intake of food containing oxalates.

A) Restrict protein intake as ordered Protein is restricted to 60 g/d, while sodium is restricted to 3 to 4 g/d. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The patient should avoid intake of oxalate-containing foods and there is no need to increase potassium intake.

37. The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? A) Smoking cessation B) Reduction of alcohol intake C) Maintenance of a diet high in vitamins and nutrients D) Vitamin D supplementation

A) Smoking cessation People who smoke develop bladder cancer twice as often as those who do not smoke. High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer.

A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patients post-procedure care? A) Strain the patients urine following the procedure. B) Administer a bolus of 500 mL normal saline following the procedure. C) Monitor the patient for fluid overload following the procedure. D) Insert a urinary catheter for 24 to 48 hours after the procedure.

A) Strain the patients urine following the procedure. Following ESWL, the nurse should strain the patients urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL.

A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic? A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy B) The need to expect a heavy menstrual period following the course of antibiotics C) The risk of developing antibiotic resistance after the course of antibiotics D) The need to undergo a series of three urine cultures after the antibiotics have been completed

A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy Yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents that affect vaginal flora. Yeast vaginitis can cause more symptoms and be more difficult and costly to treat than the original UTI. Antibiotics do not affect menstrual periods and serial urine cultures are not normally necessary. Resistance is normally a result of failing to complete a prescribed course of antibiotics.

A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN

A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. Rationale: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is given for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility

A. Antidiarrheal medications 30 minutes before a meal. Rationale: The nurse administers antidiarrheal medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injections and beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease.

An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization? A. Centers for Disease Control and Prevention (CDC) B. American Medical Association (AMA) C. Environmental Protection Agency (EPA) D. American Nurses Association (ANA)

A. Centers for Disease Control and Prevention (CDC)

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

A. Checking the client's capillary blood glucose levels regularly. Rationale: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.

A. Client will accurately identify foods that trigger symptoms. Rationale: A major focus of nursing care for the client with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the client than managing physical activity.

A nursing home resident has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? A. Contact B. Droplet C. Airborne D. Positive pressure isolation

A. Contact

A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? A. Frequent handwashing reduces transmission of pathogens from one client to another. B. Wearing gloves is known to be an adequate substitute for handwashing. C. Bar soap is preferable to liquid soap. D. Waterless products should be avoided in situations where running water is unavailable.

A. Frequent handwashing reduces transmission of pathogens from one client to another.

A nurse is preparing to administer a client's intravenous fat emulsion simultaneously with parenteral nutrition (PN). What principle should guide the nurse's action? A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B. The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D. The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. Rationale: Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The client does not need another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing.

The nurse who provides care at a wilderness camp is teaching staff members about measures that reduce campers' and workers' risks of developing Giardia infections. The nurse should emphasize which of the following practices? A. Making sure not to drink water that has not been purified B. Avoiding the consumption of wild berries C. Removing ticks safely and promptly D. Using mosquito repellent consistently

A. Making sure not to drink water that has not been purified

A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion D. Teaching the client to flush the line with sterile water E. Teaching the client when it is safe to leave the access site open to air

A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion. Rationale: An effective home care teaching program prepares the client to store solutions, set up the infusion, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Tap water is never used for flushes and the access site must never be left open to air.

28. An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy? A. Increased bone mass B. Resolution of infection C. Relief of bone pain D. Absence of tumor spread

ANS: A Rationale: Bisphosphonates such as alendronate increase bone mass and decrease bone loss by inhibiting osteoclast function. These drugs do not treat infection, pain, or tumors. PTS: 1 REF: p. 1138 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

37. An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis? A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager hump

ANS: A Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowager hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. PTS: 1 REF: p. 1135 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

11. A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem? A. Carpel tunnel syndrome B. Tendonitis C. Impingement syndrome D. Dupuytren contracture

ANS: A Rationale: Carpel tunnel syndrome may be manifested by numbness, pain, paresthesia, and weakness along the median nerve. Tendonitis is inflammation of muscle tendons. Impingement syndrome is a general term that describes all lesions that involve the rotator cuff of the shoulder. Dupuytren contracture is a slowly progressive contracture of the palmar fascia. PTS: 1 REF: p. 1118 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

16. A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which client is at greatest risk for developing chronic pharyngitis? A. A client who is a habitual user of alcohol and tobacco B. A client who is a habitual user of caffeine and other stimulants C. A client who eats a diet high in spicy foods D. A client who has gastrointestinal reflux disease (GERD)

ANS: A Rationale: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, experience chronic cough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor. PTS: 1 REF: p. 504 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

10. The emergency department (ED) nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. Which condition should the ED nurse suspect? A. Fracture of the cribriform plate B. Rupture of an ethmoid sinus C. Abrasion of the soft tissue D. Fracture of the nasal septum

ANS: A Rationale: Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum. PTS: 1 REF: p. 513 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

27. The nurse is providing education to a client diagnosed with acute rhinosinusitis. For which possible complication should the nurse teach the client to seek follow-up care? A. Periorbital edema B. Headache unrelieved by over-the-counter medications C. Clear drainage from nose D. Blood-tinged mucus when blowing the nose

ANS: A Rationale: Client teaching is an important aspect of nursing care for the client with acute rhinosinusitis. The nurse instructs the client about symptoms of complications that require follow-up. Referral to a health care provider is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the client has acute rhinosinusitis. A persistent headache does not necessarily warrant follow-up. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

31. A client has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to which complication? A. Sinus infections B. Esophageal strictures C. Pharyngitis D. Laryngitis

ANS: A Rationale: Clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of clients with these tubes is critical. Use of a nasogastric tube is not associated with the development of esophageal strictures, pharyngitis, or laryngitis. PTS: 1 REF: p. 501 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

40. A patient has come to the clinic complaining of pain just above her umbilicus. When assessing the patient, the nurse notes Sister Mary Joseph's nodules. The nurse should refer the patient to the primary care provider to be assessed for what health problem? A) A GI malignancy B) Dumping syndrome C) Peptic ulcer disease D) Esophageal/gastric obstruction

Ans: A Feedback: Palpable nodules around the umbilicus, called Sister Mary Joseph's nodules, are a sign of a GI malignancy, usually a gastric cancer. This would not be a sign of dumping syndrome, peptic ulcer disease, or esophageal/gastric obstruction.

8. The nurse is caring for a client who needs education on medication therapy for allergic rhinitis. The client is to take cromolyn daily. In providing education for this client, how should the nurse describe the action of the medication? A. It inhibits the release of histamine and other chemicals. B. It inhibits the action of proton pumps. C. It inhibits the action of the sodium-potassium pump in the nasal epithelium. D. It causes bronchodilation and relaxes smooth muscle in the bronchi.

ANS: A Rationale: Cromolyn inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

1. The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season? A. Wash hands frequently. B. Gargle with warm salt water regularly. C. Dress self and infant warmly. D. Take preventative antibiotics as prescribed.

ANS: A Rationale: Handwashing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly do not suppress transmission. In addition, antibiotics are not prescribed for a cold. PTS: 1 REF: p. 498 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

7. The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing. Which symptom is most closely associated with the early stages of laryngeal cancer? A. Hoarseness B. Dyspnea C. Dysphagia D. Frequent nosebleeds

ANS: A Rationale: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Nosebleeds are not associated with a diagnosis of laryngeal cancer. PTS: 1 REF: p. 515 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

12. A nurse is assessing a client who reports a throbbing, burning sensation in the right foot. The client states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem? A. Morton neuroma B. Pes cavus C. Hallux valgus D. Onychocryptosis

ANS: A Rationale: Morton neuroma is a swelling of the third (lateral) branch of the median plantar nerve, which causes a throbbing, burning pain, usually relieved with rest. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Hallux valgus (bunion) is a deformity in which the great toe deviates laterally and there is a marked prominence of the medial aspect of the first metatarsal-phalangeal joint and exostosis. Onychocryptosis (ingrown toenail) occurs when the free edge of a nail plate penetrates the surrounding skin, laterally or anteriorly. PTS: 1 REF: p. 1121 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

40. A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? A. The client will express satisfaction with the ability to perform ADLs. B. The client will recover from OA within 6 months. C. The client will adhere to the prescribed plan of care. D. The client will deny signs or symptoms of OA.

ANS: A Rationale: Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility, and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care; adherence is of little benefit if the regimen has no effect on the client's functional status. PTS: 1 REF: p. 1124 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

20. A client presents to a clinic reporting a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is: A. Staphylococcus aureus. B. Proteus. C. Pseudomonas. D. Escherichia coli.

ANS: A Rationale: S. aureus causes more than half of all bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent. PTS: 1 REF: p. 1142 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

6. A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia? A. Cereal with milk, a scrambled egg, and grapefruit B. Poached eggs with sausage and toast C. Waffles with fresh strawberries and powdered sugar D. A bagel topped with butter and jam with a side dish of grapes

ANS: A Rationale: The best meal option is the one that contains the highest dietary sources of calcium and vitamin D. The best selection among those listed is cereal with milk, and eggs, as these foods contain calcium and vitamin D in a higher quantity over the other menu options. PTS: 1 REF: p. 1140 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

17. A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure? A) Persistent feelings of hunger and thirst B) Constipation or bowel incontinence C) Diarrhea and feelings of fullness D) Gastric reflux and belching

Ans: C Feedback: Following a Billroth I, the patient may have problems with feelings of fullness, dumping syndrome, and diarrhea. Hunger and thirst, constipation, and gastric reflux are not adverse effects associated with this procedure.

25. A 32-year-old client comes to the clinic reporting shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the client is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing? A. Support the affected arm on pillows at night. B. Take prescribed corticosteroids as prescribed. C. Put the shoulder through its full range of motion three times daily. D. Keep the affected arm in a sling for 2 to 4 weeks.

ANS: A Rationale: The client should support the affected arm on pillows while sleeping to keep from turning onto the shoulder. Corticosteroids are not commonly prescribed and a sling is not normally necessary. ROM exercises are indicated, but putting the arm through its full ROM may cause damage during the healing process. PTS: 1 REF: p. 1118 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

24. A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? A. Stress on the weakened bone must be avoided. B. Increased heart rate enhances perfusion and bone healing. C. Bed rest results in improved outcomes in clients with osteomyelitis. D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

ANS: A Rationale: The client with osteomyelitis has bone that is weakened by the infective process and must be protected by avoidance of stress on the bone. This risk guides the choice of activity in a client with osteomyelitis. Bed rest is not normally indicated. Maintenance of prediagnosis ADLs may be an unrealistic short-term goal for many clients. PTS: 1 REF: p. 1143 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

6. The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngectomy. The nurse should encourage the client to use which appliance during recovery at home? A. A room humidifier B. An air conditioner C. A water purifier D. A radiant heater

ANS: A Rationale: The nurse stresses the importance of humidification at home and instructs the family to obtain a humidifier before the client returns home. Air conditioning may be too cool and drying for the client. A water purifier or radiant heater is not necessary. PTS: 1 REF: p. 519 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

1. A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client? A. Avoid lifting more than one-third of body weight without assistance. B. Focus on using back muscles efficiently when lifting heavy objects. C. Lift objects while holding the object a safe distance from the body. D. Tighten the abdominal muscles and lock the knees when lifting an object.

ANS: A Rationale: The nurse will instruct the client on the safe and correct way to lift objects— using the strong quadriceps muscles of the thighs, with minimal use of the weaker back muscles. To prevent recurrence of acute low back pain, the nurse may instruct the client to avoid lifting more than one-third of the client's body weight without help. The client should be informed to place the feet hip-width apart to provide a wide base of support. The person should then bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jerking. PTS: 1 REF: p. 1117 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

17. A nurse is caring for a client who is 12 hours' postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? A. Elevate the foot on several pillows. B. Apply warm compresses intermittently to the surgical area. C. Administer a loop diuretic as prescribed. D. Increase circulation through frequent ambulation.

ANS: A Rationale: To control the edema in the foot of a client who experienced foot surgery, the nurse will elevate the foot on several pillows when the client is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon. PTS: 1 REF: p. 1122 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

15. An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

ANS: A Rationale: When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is noninfectious. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septic arthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation. PTS: 1 REF: p. 1142 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

21. A nurse is providing care for a client who has a recent diagnosis of Paget disease. When planning this client's nursing care, what should interventions address? Select all that apply. A. Impaired physical mobility B. Acute pain C. Disturbed auditory sensory perception D. Risk for injury E. Risk for unstable blood glucose

ANS: A, B, C, D Rationale: Clients with Paget disease are at risk for decreased mobility, pain, hearing loss, and injuries resulting from decreased bone density. Paget disease does not affect blood glucose levels. PTS: 1 REF: p. 1141 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select

22. A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply. A. Computed tomography (CT) B. Angiography C. Magnetic resonance imaging (MRI) D. Ultrasound E. X-ray

ANS: A, C, D, E Rationale: A variety of diagnostic tests can be used to address lower back pain, including CT, MRI, ultrasound, and x-rays. Angiography is not related to the etiology of back pain. PTS: 1 REF: p. 1114 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select

25. The nurse is caring for a client with a severe nosebleed. The health care provider inserts a nasal sponge. What should the nurse teach the client about this intervention? A. The sponge creates a risk for viral sinusitis B. The sponge can stay in place for 3 to 4 days if needed C. The client should remain supine while the sponge is in place D. NSAIDs are contraindicated while the sponge is in place

ANS: B Rationale: A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 3 or 4 days if necessary to control bleeding. This does not require the client to be supine or to avoid all NSAIDs. Packing does not increase the risk for sinusitis. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

32. A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old child, who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother? A. "I will relay your request promptly to the doctor, but I suspect that the doctor won't get back to you if it's a cold." B. "I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus." C. "I'll phone in the prescription for you since it can be prescribed by the pharmacist." D. "Amoxicillin is not likely the best antibiotic, but I'll call in the right prescription for you."

ANS: B Rationale: Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the client that the health care provider will not respond to the request. PTS: 1 REF: p. 504 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

21. The nurse is performing the health interview of a client with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the client about the current medication regimen. Which medication would put the client at a higher risk for recurrent epistaxis? A. Oxymetazoline nasal B. Beclomethasone C. Levothyroxine D. Albuterol

ANS: B Rationale: Beclomethasone should be avoided in clients with recurrent epistaxis because it is a risk factor. The other listed medications do not increase the risk for epistaxis. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

8. Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17-year-old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

ANS: B Rationale: Clients who are at high risk of osteomyelitis include those who are poorly nourished, older adults, and clients who are obese. The older adult client with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this client has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The client with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The client 6 weeks' postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection. PTS: 1 REF: p. 1142 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

28. A client states that the client's family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to which factor? A. Cold viruses are increasingly resistant to common antibiotics. B. The virus is shed for 2 days prior to the emergence of symptoms. C. A genetic predisposition to viral rhinitis has recently been identified. D. Overuse of over-the-counter (OTC) cold remedies creates a "rebound" susceptibility to future colds.

ANS: B Rationale: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses, and OTC medications do not have a "rebound" effect. Genetic factors do not exist for viral rhinitis. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

30. A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care? A. Risk for aspiration related to vertebral fracture B. Constipation related to vertebral fracture C. Impaired swallowing related to vertebral fracture D. Decreased cardiac output related to vertebral fracture

ANS: B Rationale: Constipation is a problem related to immobility and medications used to treat vertebral fractures. The client's risks of aspiration, dysphagia, and decreased cardiac output are not necessarily heightened. PTS: 1 REF: p. 1139 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

16. A client has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A. Deficient fluid volume B. Delayed wound healing C. Hypocalcemia D. Pathologic fractures

ANS: B Rationale: Delayed wound healing is a complication of surgery due to tissue trauma from the surgery. Nutritional deficiency is usually due to the effects of chemotherapy and radiation therapy, which may cause weight loss. Pathologic fractures are not a complication of surgery. PTS: 1 REF: p. 1147 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

13. The nurse is conducting a presurgical interview for a client with laryngeal cancer. The client reports drinking approximately 20 oz (600 mL) of vodka per day. It is imperative that the nurse inform the surgical team so the client can be assessed for risk of which condition? A. Increased risk for infection B. Delirium tremens C. Depression D. Nonadherence to postoperative care

ANS: B Rationale: Given the client's reported alcohol intake and considering that alcoholism is a known risk factor for cancer of the larynx, it is essential to assess the client for risk of delirium tremens, which occurs among clients with alcohol use disorder during withdrawal from alcohol, such as would occur in the hospital following surgery. Infection is a risk in the postoperative period, but not an appropriate answer based on the client's history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

17. The perioperative nurse has admitted a client who has just undergone a tonsillectomy. The nurse's postoperative assessment should prioritize which potential complication of this surgery? A. Difficulty ambulating B. Hemorrhage C. Infrequent swallowing D. Bradycardia

ANS: B Rationale: Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a client after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does. PTS: 1 REF: p. 506 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

29. A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention? A. Maintenance of high Fowler positioning whenever possible B. Intermittent application of heat to the client's back C. Use of a pressure-reducing mattress D. Passive range of motion exercises

ANS: B Rationale: Intermittent local heat and back rubs promote muscle relaxation following osteoporotic vertebral fractures. High Fowler positioning is likely to exacerbate pain. The mattress must be adequately supportive, but pressure reduction is not necessarily required. Passive range of motion exercises to the back would cause pain and impair healing. PTS: 1 REF: p. 1139 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

36. A client has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the client's shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of: A. osteomyelitis. B. osteochondroma. C. osteomalacia. D. Paget disease.

ANS: B Rationale: Osteochondroma is the most common benign bone tumor. It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder). Osteomyelitis, osteomalacia, and Paget disease do not involve the development of excess bone tissue. PTS: 1 REF: p. 1145 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

33. A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? A. Hematogenous osteomyelitis B. Osteomyelitis with vascular insufficiency C. Contiguous focus osteomyelitis D. Osteomyelitis with muscular deterioration

ANS: B Rationale: Osteomyelitis is classified as hematogenous osteomyelitis (i.e., due to bloodborne spread of infection); contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound); and osteomyelitis with vascular insufficiency, seen most commonly among clients with diabetes and peripheral vascular disease, most commonly affecting the feet. Osteomyelitis with muscular deterioration does not exist. PTS: 1 REF: p. 1142 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

3. A client presents at a clinic reports heel pain that impairs walking ability. The client is subsequently diagnosed with plantar fasciitis. This client's plan of care should include what intervention? A. Wrapping the affected area in lamb's wool or gauze to relieve pressure B. Gently stretching the foot and the Achilles tendon C. Wearing open-toed shoes at all times D. Applying topical analgesic ointment to plantar surface each morning

ANS: B Rationale: Plantar fasciitis leads to pain that is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Dressings of any kind are not of therapeutic benefit and analgesic ointments do not address the pathology of the problem. Open-toed shoes are of no particular benefit. PTS: 1 REF: p. 1121 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

39. A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history. B. The client's body mass index is 34 (obese). C. The client has primary hypertension. D. The client is 58 years old.

ANS: B Rationale: Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a client who is 58 years old would not yet face a significantly heightened risk. PTS: 1 REF: p. 1122 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

18. A client with diabetes is attending a class on the prevention of associated diseases. What action should the nurse teach the client to reduce the risk of osteomyelitis? A. Increase calcium and vitamin intake. B. Monitor and control blood glucose levels. C. Exercise 3 to 4 times weekly for at least 30 minutes. D. Take corticosteroids as prescribed.

ANS: B Rationale: Since poor glycemic control can exacerbate the spread of infection from other sources, the client with diabetes should maintain blood glucose levels within a desired range. Corticosteroids can exacerbate the risk of osteomyelitis. Increased intake of calcium and vitamins as well as regular exercise are beneficial health promotion exercises, but they do not directly reduce the risk of osteomyelitis. PTS: 1 REF: p. 1142 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

33. The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. Which assessment should the nurse prioritize? A. The client's swallowing ability B. The client's airway patency C. The client's pain level D. Signs and symptoms of infection

ANS: B Rationale: The client with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters, including swallowing ability, pain level, and signs and symptoms of infection, all of which can be assessed after assessing the client's airway patency. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

37. A client has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the client asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response? A. "In many cases, this type of cancer spreads to other parts of the body." B. "This cancer usually does not spread to distant sites in the body." C. "You will have to speak to your oncologist about that." D. "When it spreads to other parts of the body, the care team will treat it aggressively."

ANS: B Rationale: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The client's prognosis is determined by the oncologist, but the client has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the client's concerns. PTS: 1 REF: p. 515 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

30. The nurse is doing discharge teaching in the ED with a client who had a nosebleed. What should the nurse include in the discharge teaching of this client? A. Avoid blowing the nose for the next 45 minutes. B. In case of recurrence, apply direct pressure for 15 minutes. C. Do not take aspirin for the next 2 weeks. D. Seek immediate medical attention if the nosebleed recurs.

ANS: B Rationale: The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the client is instructed to seek additional medical attention. ASA is not contraindicated in most cases and the client should avoid blowing the nose for an extended period of time, not just 45 minutes. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

24. The nurse is caring for a client with a history of a renal transplant who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the client asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in this client? A. The client will have exaggerated symptoms of rhinosinusitis due to immunosuppression. B. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. C. Chronic rhinosinusitis can damage the transplanted organ. D. Immunosuppressive drugs can cause organ rejection.

ANS: B Rationale: URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection. PTS: 1 REF: p. 503 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

22. The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply. A. White blood cell count B. Protein level C. Albumin level D. Platelet count E. Glucose level

ANS: B, C, E Rationale: The nurse assesses the client's general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the client's nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the client's nutritional status. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Response

36. A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment? A. A 1.5 L/day fluid restriction B. A high-potassium, low-sodium diet C. A liquid or soft diet D. A high-protein diet

ANS: C Rationale: A liquid or soft diet is provided during the acute stage of the disease, depending on the client's appetite and the degree of discomfort that occurs with swallowing. The client is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake. PTS: 1 REF: p. 504 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

13. A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A. Estrogen B. Parathyroid hormone (PTH) C. Calcitonin D. Progesterone

ANS: C Rationale: Calcitonin inhibits bone resorption and promotes bone formation, estrogen inhibits bone breakdown, and parathyroid increases bone resorption. Estrogen, which inhibits bone breakdown, decreases with aging. Parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. Progesterone is the major naturally occurring human progestogen and plays a role in the female menstrual cycle. PTS: 1 REF: p. 1136 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

23. The nurse is teaching a client with allergic rhinitis about the safe and effective use of medications. Which information would be the most essential to give this client about preventing possible drug interactions? A. Prescription medications can be safely supplemented with over-the-counter (OTC) medications. B. Use only one pharmacy so the pharmacist can check drug interactions. C. Read drug labels carefully before taking OTC medications. D. Consult the Internet before selecting an OTC medication.

ANS: C Rationale: Client education is essential when assisting the client in the use of all medications. To prevent possible drug interactions, the client is cautioned to read drug labels before taking any OTC medications. Some websites are reliable and valid information sources, but this is not always the case. Clients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

7. A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values are most characteristic of Paget disease? A. An elevated level of parathyroid hormone and low calcitonin levels B. A low serum alkaline phosphatase level and a low serum calcium level C. An elevated serum alkaline phosphatase level and a normal serum calcium level D. An elevated calcitonin level and low levels of parathyroid hormone

ANS: C Rationale: Clients with Paget disease have normal blood calcium levels. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect the increased osteoblastic activity associated with this condition. Alterations in PTH and calcitonin levels are atypical. PTS: 1 REF: p. 1141 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

2. A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation? A. Weight reduction B. Use of oral opioid analgesics C. Intermittent application of ice and heat D. Passive range of motion exercises

ANS: C Rationale: Conservative management of tendonitis includes rest of the extremity, intermittent ice and heat to the joint, and NSAIDs. Weight reduction may prevent future injuries but will not relieve existing tendonitis. Range-of-motion exercises may exacerbate pain. Opioids would not be considered a conservative treatment measure. PTS: 1 REF: p. 1117 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

29. It is cold season, and the school nurse has been asked to provide an educational event for the parent teacher organization of the local elementary school. Which information should the nurse include in education about the treatment of pharyngitis? A. Pharyngitis is more common in children whose immunizations are not up to date. B. There are no effective, evidence-based treatments for pharyngitis. C. Use of warm saline gargles or throat irrigations can relieve symptoms. D. Heat may increase the spasms in pharyngeal muscles.

ANS: C Rationale: Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. Applying heat to the throat would reduce, not increase, spasms in the pharyngeal muscles. There is no evidence that pharyngitis is more common in children whose immunizations are not up to date. Warm saline gargles and throat irrigations are evidence-based treatments for pharyngitis. PTS: 1 REF: p. 504 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

19. The nurse is caring for a client with epistaxis in the emergency department. Which information should the nurse include in client discharge teaching as a way to prevent epistaxis? A. Keep nasal passages clear. B. Use decongestants regularly. C. Humidify the indoor environment. D. Use a tissue when blowing the nose.

ANS: C Rationale: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose blowing, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated. PTS: 1 REF: p. 512 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

9. A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client? A. Strive to achieve maximum weight-bearing capabilities. B. Gradually strengthen the affected muscles through weight training. C. Support the affected extremity with external supports such as splints. D. Limit reliance on assistive devices in order to build strength.

ANS: C Rationale: During nursing care, the affected extremities must be supported and handled gently. External supports (splints) may be used for additional protection. Prescribed weight-bearing restrictions must be followed. Assistive devices should be used to strengthen the unaffected extremities. PTS: 1 REF: p. 1147 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

5. The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A. Anxiety related to diagnosis of cancer B. Altered nutrition related to swallowing difficulties C. Ineffective airway clearance related to airway alterations D. Impaired verbal communication related to removal of the larynx

ANS: C Rationale: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions. PTS: 1 REF: p. 516 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

12. The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client reports having hereditary angioedema. The nurse should identify which implication of this health condition? A. It will result in increased loss of work days. B. It may cause episodes of weakness due to reduced cardiac output. C. It can cause life-threatening airway obstruction. D. It is a risk factor for ischemic heart disease.

ANS: C Rationale: Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work, reduced cardiac function, or ischemic heart disease. PTS: 1 REF: p. 514 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

3. The nurse is creating a plan of care for a client diagnosed with acute laryngitis. Which intervention should be included in the client's plan of care? A. Place warm washcloths on the client's throat, as needed. B. Have the client inhale warm steam three times daily. C. Encourage the client to limit speech whenever possible. D. Limit the client's fluid intake to 1.5 L/day.

ANS: C Rationale: Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool, not warm, steam or an aerosol. Fluid intake should be increased, not limited. Warm washcloths on the throat will not help relieve the symptoms of acute laryngitis. PTS: 1 REF: p. 507 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

26. A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? A. Teaching focuses on safe and effective use of antibiotics. B. The client should be preliminarily screened for surgery. C. Symptom management is the main focus of medical and nursing care. D. The focus of care is resting the voice to prevent chronic hoarseness.

ANS: C Rationale: Nursing care for clients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance. PTS: 1 REF: p. 504 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

18. A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of which health problem? A. Adenoiditis B. Chronic tonsillitis C. Obstructive sleep apnea D. Laryngeal cancer

ANS: C Rationale: Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This client's symptoms are not suggestive of laryngeal cancer. PTS: 1 REF: p. 510 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

10. A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? A. Bursitis B. Radiculopathy C. Sciatica D. Tendonitis

ANS: C Rationale: Sciatica nerve pain travels down the back of the thigh to the foot of the affected leg. Bursitis is inflammation of a fluid-filled sac in a joint. Radiculopathy is disease of a nerve root. Tendonitis is inflammation of muscle tendons. PTS: 1 REF: p. 1114 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

31. A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What of the following risk factors should the educator describe? A. Recurrent infections and prolonged use of NSAIDs B. High alcohol intake and low body mass index C. Small frame and female sex D. Male sex, diabetes, and high protein intake

ANS: C Rationale: Small-framed women are at greatest risk for osteoporosis. Diabetes, high protein intake, alcohol use, and infections are not among the most salient risk factors for osteoporosis. PTS: 1 REF: p. 1136 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

34. The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse's best action? A. Remove the client's drain and apply pressure with a sterile gauze. B. Assess the client, reposition the client supine, and apply wall suction to the drain. C. Rapidly assess the client and notify the surgeon about the client's bleeding. D. Administer a STAT dose of vitamin K to aid coagulation.

ANS: C Rationale: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be given without an order. PTS: 1 REF: p. 520 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

32. A nurse is providing care for a client who has osteomalacia. What major goal should guide the choice of medical and nursing interventions? A. Maintenance of skin integrity B. Prevention of bone metastasis C. Maintenance of adequate levels of activated vitamin D D. Maintenance of adequate parathyroid hormone function

ANS: C Rationale: The primary defect in osteomalacia is a deficiency of activated vitamin D, which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. Interventions are aimed at resolving the processes underlying this deficiency. Maintenance of skin integrity is important, but is not the primary goal in care. Osteomalacia is not a malignant process. Overproduction (not underproduction) of PTH can cause the disease. PTS: 1 REF: p. 1140 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

35. The nurse is creating a care plan for a client who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. Which form of alaryngeal communication is generally most preferred? A. Esophageal speech B. Electric larynx C. Tracheoesophageal puncture D. American sign language (ASL)

ANS: C Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, electric larynx, and ASL. PTS: 1 REF: p. 517 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice

20. The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? A. Assessment of body image B. Assessment of jugular venous pressure C. Assessment of carotid pulse D. Assessment of swallowing ability

ANS: D Rationale: A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The client's body image should be assessed, but dysphagia has the potential to affect the client's airway, and is a consequent priority. PTS: 1 REF: p. 520 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

9. The nurse is caring for a client who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the client to tilt the head forward, and the nurse applies pressure to the nose, but the client's nose continues to bleed. Which intervention should the nurse next implement? A. Apply ice to the bridge of the nose. B. Lay the client down. C. Arrange for transfer to the local emergency department. D. Insert a cotton tampon in the affected nare.

ANS: D Rationale: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down could block the client's airway. Transfer to the emergency department is necessary only if the bleeding becomes serious. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

5. A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis. B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause. D. The use of corticosteroids increases the risk of osteoporosis.

ANS: D Rationale: Corticosteroid therapy is a secondary cause of osteoporosis when taken for long-term use. Adequate levels of vitamin D are needed for absorption of calcium. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause. PTS: 1 REF: p. 1134 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

2. A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which action? A. Apply a cold pack to the affected area. B. Apply heat to the forehead. C. Perform postural drainage. D. Increase fluid intake.

ANS: D Rationale: For a client diagnosed with acute sinusitis, the nurse should instruct the client that increasing fluid intake and elevating the head of the bed can promote drainage. Applying a cold pack to the affected area and applying heat to the forehead will not promote sinus drainage. Postural drainage is used to remove bronchial secretions. PTS: 1 REF: p. 502 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A. Standard precautions only B. Droplet precautions C. Standard and contact precautions D. Standard and airborne precautions

D. Standard and airborne precautions

38. An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize what aspect of care? A. Administration of oral and IV corticosteroids as prescribed B. Prevention of falls and pathologic fractures C. Maintenance of adequate serum levels of vitamin D D. Intravenous administration of antibiotics

ANS: D Rationale: IV antibiotics are the major treatment modality for septic arthritis; the nurse must ensure timely administration of these drugs. Corticosteroids are not used to treat septic arthritis and vitamin D levels are not necessarily affected. Falls prevention is important, but septic arthritis does not constitute the same fracture risk as diseases with decreased bone density. PTS: 1 REF: p. 1145 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

4. A client is being treated in the emergency department for epistaxis. Pressure has been applied to the client's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using which treatment to control the bleeding? A. Irrigation with a hypertonic solution B. Nasopharyngeal suction C. Normal saline application D. Silver nitrate application

ANS: D Rationale: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis. Normal saline application would not alleviate epistaxis. PTS: 1 REF: p. 512 NAT: Client Needs: Safe, Effective Care Environment: Management of Care |Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

11. A 42-year-old client is admitted to the ED after an assault. The client received blunt trauma to the face and has a suspected nasal fracture. What intervention should the nurse perform? A. Administer nasal spray and apply an occlusive dressing to the client's face. B. Position the client's head in a dependent position. C. Irrigate the client's nose with warm tap water. D. Apply ice and keep the client's head elevated.

ANS: D Rationale: Immediately after the fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used. PTS: 1 REF: p. 513 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

26. A client presents at the clinic with a report of morning numbness, cramping, and stiffness in the fourth and fifth fingers of the right hand. What disease process should the nurse suspect? A. Tendonitis B. A ganglion C. Carpal tunnel syndrome D. Dupuytren disease

ANS: D Rationale: In cases of Dupuytren disease, the client may experience dull, aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected. This clinical scenario does not describe tendonitis, a ganglion, or carpal tunnel syndrome. PTS: 1 REF: p. 1118 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

38. A client's total laryngectomy has created a need for alaryngeal speech, which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the client when teaching about this process? A. Training how to perform controlled belching B. Use of an electronically enhanced artificial pharynx C. Insertion of a specialized nasogastric tube D. Fitting for a voice prosthesis

ANS: D Rationale: In clients receiving tracheoesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used. PTS: 1 REF: p. 517 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

14. A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? A. High chloride, calcium, and magnesium levels B. High parathyroid and calcitonin levels C. Low serum calcium and magnesium levels D. Low serum calcium and low phosphorus level

ANS: D Rationale: Laboratory studies in clients with osteomalacia will reveal a low serum calcium and low phosphorus level. PTS: 1 REF: p. 1140 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

34. An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. What nursing intervention should be included in the client's subsequent care? A. Dressing changes should not be performed unless there are clear signs of infection. B. The surgical site can be soaked in warm bath water for up to 5 minutes. C. The surgical site should be cleansed with hydrogen peroxide once daily. D. The foot should be elevated in order to prevent edema.

ANS: D Rationale: Pain experienced by clients who undergo foot surgery is related to inflammation and edema. To control the anticipated edema, the foot should be elevated on several pillows when the client is sitting or lying. Regular dressing changes are performed and the wound should be kept dry. Hydrogen peroxide is not used to cleanse surgical wounds. PTS: 1 REF: p. 1122 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

23. A nurse is reviewing the care of a client who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? A. Calcitonin B. Prednisone C. Aspirin D. Cyclobenzaprine

ANS: D Rationale: Short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain. ASA is not normally used for pain control, due to its antiplatelet action and associated risk for bleeding. Calcitonin and corticosteroids are not usually used in the treatment of lower back pain. PTS: 1 REF: p. 1115 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

15. The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. One day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client? A. Keep the remaining tablets for an infection at a later time. B. Discontinue the medications if the fever is gone. C. Dispose of the remaining medication in a biohazard receptacle. D. Finish all the antibiotics to eliminate the organism completely.

ANS: D Rationale: The nurse informs the client about the need to take the full course of any prescribed antibiotic. Antibiotics should be taken for the entire prescribed course to eliminate the microorganisms. A client should never be instructed to keep leftover antibiotics for use at a later time. Even if the fever or other symptoms are gone, the medications should be continued. Antibiotics do not need to be disposed of in a biohazard receptacle, though they should be discarded appropriately. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

4. A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

ANS: D, E Rationale: A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12 and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient. PTS: 1 REF: p. 1134 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 36: Assessment and Management of Clients with Musculoskeletal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select

Which action should the nurse take first when providing care for a client during an acute asthma attack? Administer prescribed short-acting bronchodilator. Send for STAT chest x-ray. Obtain arterial blood gases. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

Administer prescribed short-acting bronchodilator.

14. A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A) Esophageal or pyloric obstruction related to scarring B) Uncontrolled proliferation of H. pylori C) Gastric hyperacidity related to excessive gastrin secretion D) Chronic referred pain in the lower abdomen

Ans: A Feedback: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a patient who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.

16. A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having "trouble swallowing" for the past few days. What recommendation should the nurse make? A) Eating more slowly and chewing food more thoroughly B) Taking an OTC antacid or drinking a glass of milk prior to each meal C) Chewing gum to cause relaxation of the lower esophageal sphincter D) Drinking at least 12 ounces of liquid with each meal

Ans: A Feedback: Dysphagia may be prevented by educating patients to eat slowly, to chew food thoroughly, and to avoid eating tough foods such as steak or dry chicken or doughy bread. After bariatric procedures, patients should normally not drink beverages with meals. Medications or chewing gum will not alleviate this problem.

12. A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what? A) Infection with Helicobacter pylori B) Excessive stomach acid secretion C) An incompetent pyloric sphincter D) A metabolic acid-base imbalance

Ans: A Feedback: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acidbase imbalances do not cause peptic ulcer disease.

2. A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? A) "Does your pain resolve when you have something to eat?" B) "Do over-the-counter pain medications help your pain?" C) "Does your pain get worse if you get up and do some exercise?" D) "Do you find that your pain is worse when you need to have a bowel movement?"

Ans: A Feedback: Pain relief after eating is associated with duodenal ulcers. The pain of peptic ulcers is generally unrelated to activity or bowel function and may or may not respond to analgesics.

38. A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patient's continuing care in the home setting, what assessment question is most relevant? A) "Does anyone in your family have experience at giving injections?" B) "Are you going to be anywhere with strong sunlight in the next few months?" C) "Are you aware of your blood type?" D) "Do any of your family members have training in first aid?"

Ans: A Feedback: Patients with malabsorption of vitamin B12 need information about lifelong vitamin B12 injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the patient to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant.

8. A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying? A) Fowler's B) Supine C) Left lateral D) Left Sim's

Ans: A Feedback: Positioning the patient in a Fowler's position postoperatively promotes comfort and facilitates emptying of the stomach following gastric surgery. Any position that involves lying down delays stomach emptying and is not recommended for this type of patient. Supine positioning and the left lateral (left Sim's) position do not achieve this goal.

3. A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action? A) "This medication will reduce the amount of acid secreted in your stomach." B) "This medication will make the lining of your stomach more resistant to damage." C) "This medication will specifically address the pain that accompanies peptic ulcer disease." D) "This medication will help your stomach lining to repair itself."

Ans: A Feedback: Proton pump inhibitors like Prilosec inhibit the synthesis of stomach acid. PPIs do not increase the durability of the stomach lining, relieve pain, or stimulate tissue repair.

29. A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? A) Examine one's own attitudes towards obesity in general and the patient in particular. B) Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. C) Describe one's own struggles with weight gain and weight loss to the patient. D) Elicit the patient's short-term and long-term goals for weight loss.

Ans: A Feedback: Studies suggest that health care providers, including nurses, harbor negative attitudes towards obese patients. Nurses have a responsibility to examine these attitudes and change them accordingly. This is foundational to all other areas of assessing this patient.

11. A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence? A) Tachycardia, hypotension, and tachypnea B) Tarry, foul-smelling stools C) Diaphoresis and sudden onset of abdominal pain D) Sudden thirst, unrelieved by oral fluid administration

Ans: A Feedback: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Patients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.

35. A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines? A) Eat small, frequent meals with high calorie and vitamin content. B) Eat frequent meals with an equal balance of fat, carbohydrates, and protein. C) Eat frequent, low-fat meals with high protein content. D) Try to maintain the pre-diagnosis pattern of eating.

Ans: A Feedback: The nurse encourages the patient to eat small, frequent portions of nonirritating foods to decrease gastric irritation. Food supplements should be high in calories, as well as vitamins A and C and iron, to enhance tissue repair.

39. A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply. A) Specific lifestyle changes associated with each procedure B) Implications of each procedure for eating habits C) Effects of different surgeries on bowel function D) Effects of various bariatric surgeries on fertility E) Effects of different surgeries on safety of future immunizations

Ans: A, B, C Feedback: Different bariatric surgical procedures entail different lifestyle modifications; patients must be well informed about the specific lifestyle changes, eating habits, and bowel habits that may result from a particular procedure. Bariatric surgeries do not influence the future use of immunizations or fertility, though pregnancy should be avoided for 18 months after bariatric surgery.

6. A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patient's discharge. Which of the following is essential to include? A) Drink a minimum of 12 ounces of fluid with each meal. B) Eat several small meals daily spaced at equal intervals. C) Choose foods that are high in simple carbohydrates. D) Sit upright when eating and for 30 minutes afterward.

Ans: B Feedback: Due to decreased stomach capacity, the patient must consume small meals at intervals to meet nutritional requirements while avoiding a feeling of fullness and complications such as dumping syndrome. The patient should not consume fluids with meals and low-Fowler's positioning is recommended during and after meals. Carbohydrates should be limited.

34. A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patient's level of anxiety. Which of the following actions is most likely to accomplish this? A) The nurse gauges the patient's response to hypothetical outcomes. B) The patient is encouraged to express fears openly. C) The nurse provides detailed and accurate information about the disease. D) The nurse closely observes the patient's body language.

Ans: B Feedback: Encouraging the patient to discuss his or her fears and anxieties is usually the best way to assess a patient's anxiety. Presenting hypothetical situations is a surreptitious and possibly inaccurate way of assessing anxiety. Observing body language is part of assessment, but it is not the complete assessment. Presenting information may alleviate anxiety for some patients, but it is not an assessment.

10. A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient? A) Most affected patients acquired the infection during international travel. B) Infection typically occurs due to ingestion of contaminated food and water. C) Many people possess genetic factors causing a predisposition to H. pylori infection. D) The H. pylori microorganism is endemic in warm, moist climates.

Ans: B Feedback: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to all areas of the United States. Genetic factors have not been identified.

19. A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what? A) Knowledge of the causes of obesity and its associated risks B) Adequate understanding of required lifestyle changes C) Positive body image and high self-esteem D) Insight into why past weight loss efforts failed

Ans: B Feedback: Patients seeking bariatric surgery should be free of serious mental disorders and motivated to comply with lifestyle changes related to eating patterns, dietary choices, and elimination. While assessment of knowledge about causes of obesity and its associated risks as well as insight into the reasons why previous diets have been ineffective are included in the client's plan of care, these do not predict positive client outcomes following bariatric surgery. Most obese patients have an impaired body image and alteration in self-esteem. An obese patient with a positive body image would be unlikely to seek this surgery unless he or she was experiencing significant comorbidities.

30. A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment? A) Bowel incontinence B) Flatus with oily discharge C) Abdominal pain D) Heat intolerance

Ans: B Feedback: Side effects of orlistat include increased frequency of bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance.

23. A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. A) Malignant hyperthermia B) Atelectasis C) Pneumonia D) Metabolic imbalances E) Chronic gastritis

Ans: B, C, D Feedback: After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as pneumonia, atelectasis, or metabolic imbalances resulting from the GI disruption. Malignant hyperthermia is an intraoperative complication. Chronic gastritis is not a surgical complication.

5. A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient? A) The patient's bowel movements maintain a loose consistency. B) The patient is able to tolerate three large meals a day. C) The patient maintains or gains weight. D) The patient consumes a diet high in calcium.

Ans: C Feedback: Expected outcomes for the patient following gastric surgery include ensuring that the patient is maintaining or gaining weight (patient should be weighed daily), experiencing no excessive diarrhea, and tolerating six small meals a day. Patients may require vitamin B12 supplementation by the intramuscular route and do not require a diet excessively rich in calcium.

20. A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug? A) It reduces the stomach's volume of hydrochloric acid B) It increases the speed of gastric emptying C) It protects the stomach's lining D) It increases lower esophageal sphincter pressure

Ans: C Feedback: Misoprostol is a synthetic prostaglandin that, like prostaglandin, protects the gastric mucosa. NSAIDs decrease prostaglandin production and predispose the patient to peptic ulceration. Misoprostol does not reduce gastric acidity, improve emptying of the stomach, or increase lower esophageal sphincter pressure.

7. A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patient's health problem? A) Consumes one or more protein drinks daily. B) Takes over-the-counter antacids frequently throughout the day. C) Smokes one pack of cigarettes daily. D) Reports a history of social drinking on a weekly basis.

Ans: C Feedback: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in patients with a history of consumption of alcohol on a daily basis.

31. A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity? A) "Weight loss drugs have many side effects, and most doctors think they'll all be off the market in a few years." B) "There used to be a lot of hope that medications would help people lose weight, but it's been shown to be mostly a placebo effect." C) "Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone." D) "Medications are rapidly become the preferred method of weight loss in people for whom diet and exercise have not worked."

Ans: C Feedback: Though antiobesity drugs help some patients lose weight, their use rarely results in loss of more than 10% of total body weight. Patients are consequently unlikely to attain their desired weight through medication alone. They are not predicted to disappear from the market and results are not attributed to a placebo effect.

13. A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide? A) Take the medication on an empty stomach. B) Take up to one extra dose per day if stomach pain persists. C) Take at bedtime to mitigate the effects of drowsiness. D) Avoid drinking alcohol while taking the drug.

Ans: D Feedback: Alcohol must be avoided when taking Flagyl and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the patient.

32. A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists B) H2 antagonists, antibiotics, and bicarbonate salts C) Bicarbonate salts, antibiotics, and ZES D) Antibiotics, proton pump inhibitors, and bismuth salts

Ans: D Feedback: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. H2 receptor antagonists are used to treat NSAID-induced ulcers and other ulcers not associated with H. pylori infection, but they are not the drug of choice. Bicarbonate salts are not used. ZES is the Zollinger-Ellison syndrome and not a drug.

22. A patient has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the patient at this time? A) Teaching the patient about necessary nutritional modification B) Helping the patient weigh treatment options C) Teaching the patient about the etiology of gastritis D) Providing the patient with physical and emotional support

Ans: D Feedback: For acute gastritis, the nurse provides physical and emotional support and helps the patient manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed patient; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time.

18. A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Irritation of the phrenic nerve due to diaphragmatic pressure B) Chronic malabsorption of iron and vitamins A and C C) Reflux of bile into the distal esophagus D) A sudden release of peptides

Ans: D Feedback: For many years, it had been theorized that the hypertonic gastric food boluses that quickly transit into the intestines drew extracellular fluid from the circulating blood volume into the small intestines to dilute the high concentration of electrolytes and sugars, resulting in symptoms. Now, it is thought that this rapid transit of the food bolus from the stomach into the small intestines instead causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux.

37. A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A) Strategies for maintaining an alkaline gastric environment B) Safe technique for self-suctioning C) Techniques for positioning correctly to promote gastric healing D) Strategies for avoiding irritating foods and beverages

Ans: D Feedback: Measures to help relieve pain include instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the patient about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing.

9. A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A) Enteral feeding via gastrostomy tube (G tube) B) Gastrointestinal decompression by nasogastric tube C) Periodic assessment for esophageal distension D) Monthly administration of injections of vitamin B12

Ans: D Feedback: Since vitamin B12 is absorbed in the stomach, the patient requires vitamin B12 replacement to prevent pernicious anemia. A gastrectomy precludes the use of a G tube. Since the stomach is absent, a nasogastric tube would not be indicated. As well, this is not possible in the home setting. Since there is no stomach to act as a reservoir and fluids and nutrients are passing directly into the jejunum, distension is unlikely.

4. A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patient's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage? A) Gastric cancer does not cause signs or symptoms until metastasis has occurred. B) Adherence to screening recommendations for gastric cancer is exceptionally low. C) Early symptoms of gastric cancer are usually attributed to constipation. D) The early symptoms of gastric cancer are usually not alarming or highly unusual.

Ans: D Feedback: Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation.

36. A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to be tachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of consciousness, what would be a priority nursing action for this patient? A) Place the patient in a prone position. B) Provide the patient with ice water to slow any GI bleeding. C) Prepare for the insertion of an NG tube. D) Notify the physician.

Ans: D Feedback: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patient's vital signs are monitored as the patient's condition warrants. Putting the patient in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.

25. A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A) Ask the patient's primary care provider to liaise between the nurse and the patient. B) Delegate care of the patient to a colleague. C) Limit contact with the patient in order to provide privacy. D) Make appropriate referrals to services that provide psychosocial support.

Ans: D Feedback: The nurse should enlist the services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists, if needed. This is preferable to delegating care, since the patient has become angry with other care providers as well. It is impractical and inappropriate to expect the primary care provider to act as a liaison. It would be inappropriate and unsafe to simply limit contact with the patient.

A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient? A) A patient whose diagnosis of chronic kidney disease requires a fluid restriction B) A patient who has Alzheimers disease and who is acutely agitated C) A patient who is on bed rest following a recent episode of venous thromboembolism D) A patient who has decreased mobility following a transmetatarsal amputation

B) A patient who has Alzheimer's disease and who is acutely agitated Patients who are confused and agitated risk trauma through the removal of an indwelling catheter which has the balloon still inflated. Recent VTE, amputation, and fluid restriction do not directly create a risk for injury or trauma associated with indwelling catheter use.

The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurses best response to this finding? A) Perform a straight catheterization on this patient. B) Avoid further interventions at this time, as this is an acceptable finding. C) Place an indwelling urinary catheter. D) Press on the patients bladder in an attempt to encourage complete emptying.

B) Avoid further interventions at this time, as this is an acceptable finding. In adults older than 60 years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Consequently, further interventions are not likely warranted.

A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patients discharge education, what is the most plausible nursing diagnosis that the nurse should address? A) Impaired mobility related to limitations posed by the ileal conduit B) Deficient knowledge related to care of the ileal conduit C) Risk for deficient fluid volume related to urinary diversion D) Risk for autonomic dysreflexia related to disruption of the sacral plexus

B) Deficient knowledge related to care of the ileal conduit The patient will most likely require extensive teaching about the care and maintenance of a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit. Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral plexus is not threatened by the creation of a urinary diversion.

A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patients body image? A) Emphasize that the diversion is an integral part of successful cancer treatment. B) Encourage the patient to speak openly and frankly about the diversion. C) Allow the patient to initiate the process of providing care for the diversion. D) Provide the patient with detailed written materials about the diversion at the time of discharge.

B) Encourage the patient to speak openly and frankly about the diversion. Allowing the patient to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the patient is hesitant. Provision of educational materials is rarely sufficient to address a sudden change and profound change in body image. Emphasizing the role of the diversion in cancer treatment does not directly address the patients body image.

Resection of a patients bladder tumor has been incomplete and the patient is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the patient, the nurse should emphasize the need to do which of the following? A) Remain NPO for 12 hours prior to the treatment. B) Hold the solution in the bladder for 2 hours before voiding. C) Drink the intravesical solution quickly and on an empty stomach. D) Avoid acidic foods and beverages until the full cycle of treatment is complete.

B) Hold the solution in the bladder for 2 hours before voiding. The patient is allowed to eat and drink before the instillation procedure. Once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding. The solution is instilled through the meatus; it is not consumed orally. There is no need to avoid acidic foods and beverages during treatment.

A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patients discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt? A) Increasing intake of protein from plant sources B) Increasing fluid intake C) Adopting a high-calcium diet D) Eating several small meals each day

B) Increasing fluid intake A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patients discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt? A) Increasing intake of protein from plant sources B) Increasing fluid intake C) Adopting a high-calcium diet D) Eating several small meals each day

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population? A) Administer prophylactic antibiotics as ordered. B) Limit the use of indwelling urinary catheters. C) Encourage frequent mobility and repositioning. D) Toilet residents who are immobile on a scheduled basis.

B) Limit the use of indwelling urinary catheters. When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adults risk of developing a UTI. Regular toileting promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally administered. Mobility does not have a direct effect on UTI risk.

A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patients plan of care? A) Impaired physical mobility related to presence of an indwelling urinary catheter B) Risk for infection related to presence of an indwelling urinary catheter C) Toileting self-care deficit related to urinary catheterization D) Disturbed body image related to urinary catheterization

B) Risk for infection related to presence of an indwelling urinary catheter Catheters create a high risk for UTIs. Because of this acute physiologic threat, the patients risk for infection is usually prioritized over functional and psychosocial diagnoses.

A nurse is caring for a female patient whose urinary retention has not responded to conservative treatment. When educating this patient about self-catheterization, the nurse should encourage what practice? A) Assuming a supine position for self-catheterization B) Using clean technique at home to catheterize C) Inserting the catheter 1 to 2 inches into the urethra D) Self-catheterizing every 2 hours at home

B) Using clean technique at home to catheterize The patient may use a clean (nonsterile) technique at home, where the risk of cross-contamination is reduced. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The female patient assumes a Fowlers position and uses a mirror to help locate the urinary meatus. The nurse teaches her to catheterize herself by inserting a catheter 7.5 cm (3 inches) into the urethra, in a downward and backward direction.

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

B. Increased fiber intake D. Reduced fat intake Rationale: Clients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.

A client is alarmed about testing positive for MRSA following culture testing during admission to the hospital. What should the nurse teach the client about this diagnostic finding? A. "There are promising treatments for MRSA, so this is no cause for serious concern." B. "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces." C. "The vast majority of clients in the hospital test positive for MRSA, but the infection doesn't normally cause serious symptoms." D. "This finding is only preliminary, and your doctor will likely order further testing."

B. "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces."

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A. A 45-year-old teacher who stands for 6 hours per day B. A pregnant woman at 28 weeks' gestation C. A 37-year-old construction worker who does heavy lifting D. A 60-year-old professional who is under stress

B. A pregnant woman at 28 weeks' gestation Rationale: Hemorrhoids commonly affect 50% of clients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements

B. Assess the client's food and fluid intake. Rationale: The nurse should follow the nursing process and perform an assessment prior to interventions. The client's food and fluid intake is more likely to affect bowel function than surgery.

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A. Use clean technique and wear a mask during dressing changes. B. Change the dressing no more than weekly. C. Apply antibiotic ointment around the site with each dressing change. D. Irrigate the insertion site with sterile water during each dressing change.

B. Change the dressing no more than weekly. Rationale: CVAD dressings are changed every 7 days unless the dressing is damp, bloody, loose, or soiled, in which case they should be changed more often. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not normally used.

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? A. Dumping syndrome B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis

B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis Rationale: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

A client is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute? A. Contact precautions B. Droplet precautions C. Airborne precautions D. Observation precautions

B. Droplet precautions

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies. B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

B. Engage the client in dialogue about the implications of having the colostomy. Rationale: For many clients, being able to dialogue frankly about the effect of the ostomy with a nonjudgmental nurse is helpful. Emphasizing the benefits of the intervention is unlikely to improve the client's body image, since the benefits are likely already known. Online research is not likely to enhance the client's body image and some ostomies are permanent.

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence

B. Foul-smelling diarrhea that contains fat. Rationale: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.

A client with a diagnosis of colon cancer is 2 days' postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Close monitoring of temperature B. Frequent abdominal auscultation C. Assessment of hemoglobin, hematocrit, and red blood cell levels D. Palpation of peripheral pulses and leg girth

B. Frequent abdominal auscultation Rationale: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse. Obstruction can develop more quickly than infection in most cases.

During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A. Regular application of an OTC antibiotic ointment B. Increased fluid and fiber intake C. Daily use of OTC glycerin suppositories D. Use of an NSAID to reduce inflammation

B. Increased fluid and fiber intake Rationale: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem.

A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included? A. Risk for peripheral neurovascular dysfunction related to catheter placement B. Ineffective role performance related to parenteral nutrition C. Bowel incontinence related to parenteral nutrition D. Chronic pain related to catheter placement

B. Ineffective role performance related to parenteral nutrition. Rationale: The limitations associated with PN can make it difficult for clients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance C. Changing the rate of administration every 2 hours based on serum electrolyte values D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance. Rationale: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the client's fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual client based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B. Report signs and symptoms of obstruction to the health care provider. C. Encourage the client to mobilize in order to enhance motility. D. Contact the health care provider and obtain a swab of the stoma for culture

B. Report signs and symptoms of obstruction to the health care provider. Rationale: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma because infection is unrelated to this problem.

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis

B. Risk for infection related to possible rupture of appendix Rationale: The client with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? A. Risk for activity intolerance related to the presence of a subclavian catheter B. Risk for infection related to the presence of a subclavian catheter C. Risk for functional urinary incontinence related to the presence of a subclavian catheter D. Risk for sleep deprivation related to the presence of a subclavian catheter

B. Risk for infection related to the presence of a subclavian catheter. Rationale: The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The client will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these

A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this client? A. The appropriate use of antibiotics to prevent postoperative infection B. The correct procedure for taking a sitz bath C. The need to eat a low-residue, low-fat diet for the next 2 weeks D. The correct technique for keeping the perianal region clean without the use of water

B. The correct procedure for taking a sitz bath. Rationale: Sitz baths are usually indicated after perianal surgery. A low-residue, low-fat diet is not necessary and water is used to keep the region clean. Postoperative antibiotics are not routinely prescribed.

What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? A. To decrease nurses' susceptibility to health care-associated infections B. To decrease risk of transmission to vulnerable clients C. To eventually eradicate the influenza virus in the United States D. To prevent the emergence of drug-resistant strains of the influenza virus

B. To decrease risk of transmission to vulnerable clients

A nurse is educating a group of students about stages of syphilis. Which is true for secondary syphilis? A. Chancres will resolve without treatment. B. Transmission can occur with contact with chancres. C. Multiple organ involvement occurs. D. Neurological symptoms occur.

B. Transmission can occur with contact with chancres.

An older adult client tells the nurse that the client had chicken pox as a child and is eager to be vaccinated against shingles. What should the nurse teach the client about this vaccine? A. Vaccination against shingles is contraindicated in clients over the age of 80. B. Vaccination can reduce the risk of shingles by approximately 50%. C. Vaccination against shingles involves a series of three injections over the course of 6 months. D. Vaccination against shingles is only effective if preceded by a childhood varicella vaccination.

B. Vaccination can reduce the risk of shingles by approximately 50%.

A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? A. Wearing a mask and gown when starting an IV line B. Washing hands immediately after removing gloves C. Recapping all needles promptly after use to prevent needlestick injuries D. Double-gloving when working with a client who has a bloodborne illness

B. Washing hands immediately after removing gloves

A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? A. Labile BP B. Weak pulse C. Fever D. Diaphoresis

B. Weak pulse

A male client with gonorrhea asks the nurse how they can reduce the risk of contracting another sexually transmitted infection (STI). The client is not in a monogamous relationship. The nurse should instruct the client to do what action? A. Ask all potential sexual partners if they have an STI. B. Wear a condom every time the client has intercourse. C. Consider intercourse to be risk-free if the partner has no visible discharge, lesions, or rashes. D. Aim to limit the number of sexual partners to fewer than five over their lifetime.

B. Wear a condom every time the client has intercourse.

1. A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? A) Bathe daily and keep the perineal region clean. B) Avoid voiding immediately after sexual intercourse. C) Drink liberal amounts of fluids. D) Void at least every 6 to 8 hours.

C) Drink liberal amounts of fluids The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacteria from the urinary tract. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. The patient should be encouraged to shower rather than bathe.

The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter? A) Vigorously clean the meatus area daily. B) Apply powder to the perineal area twice daily. C) Empty the drainage bag at least every 8 hours. D) Irrigate the catheter every 8 hours with normal saline.

C) Empty the drainage bag at least every 8 hours To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at least every 8 hours through the drainage spout, and more frequently if there is a large volume of urine. Vigorous cleaning of the meatus while the catheter is in place is discouraged, because the cleaning action can move the catheter, increasing the risk of infection. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Irrigation of the catheter opens the closed system, increasing the likelihood of infection.

A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patients admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply. A) Diarrhea B) High fever C) Hematuria D) Urinary frequency E) Acute pain

C) Hematuria D) Urinary frequency E) Acute pain Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation and a fever is usually absent due to the noninfectious nature of the health problem.

The nurse advises the patient who has just been diagnosed with acute gastritis to: Take an emetic to rid the stomach of the irritating products. Refrain from food until the GI symptoms subside. Restrict food and fluids for 12 hours. Restrict all food for 72 hours to rest the stomach.

Refrain from food until the GI symptoms subside. Explanation: It usually takes 24 to 48 hours for the stomach to recover from an attack. Refraining from food until symptoms subside is recommended, but liquids should be taken in moderation. Emetics and vomiting can cause damage to the esophagus. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1268

A patient has had her indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the patient informs the nurse that she is experiencing urinary urgency resulting in several small-volume voids. What is the nurses best response? A) Inform the patient that urgency and occasional incontinence are expected for the first few weeks post-removal. B) Obtain an order for a loop diuretic in order to enhance urine output and bladder function. C) Inform the patient that this is not unexpected in the short term and scan the patients bladder following each void. D) Obtain an order to reinsert the patients urinary catheter and attempt removal in 24 to 48 hours.

C) Inform the patient that this is not unexpected in the short term and scan the patients bladder following each void. Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner; if the bladder has not emptied completely, straight catheterization may be performed. An indwelling catheter would not be reinserted to resolve the problem and diuretics would not be beneficial. Ongoing incontinence is not an expected finding after catheter removal.

The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient? A) Limit oral fluid intake for 1 to 2 days. B) Report the presence of fine, sand like particles through the nephrostomy tube. C) Notify the physician about cloudy or foul-smelling urine. D) Report any pink-tinged urine within 24 hours after the procedure.

C) Notify the physician about cloudy or foul-smelling urine. The patient should report the presence of foul-smelling or cloudy urine since this is suggestive of a UTI. Unless contraindicated, the patient should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand like debris is normal due to residual stone products. Hematuria is common after lithotripsy.

A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patients cardiopulmonary status is stable, what aspect of care should the nurse prioritize? A) IV fluid administration B) Insertion of an indwelling urinary catheter C) Pain management D) Assisting with aspiration of the stone

C) Pain management The patient with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the patients need for IV fluids or for catheterization. Kidney stones cannot be aspirated.

A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient? A) Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence. B) Remind the patient that occasional febrile episodes are expected following ESWL. C) Tell the patient to report to the ED for further assessment. D) Tell the patient to monitor his temperature for the next 24 hours and then contact his urologists office.

C) Tell the patient to report to the ED for further assessment. Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.

A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? A) The circumference of the stoma B) The narrowest part of the stoma C) The widest part of the stoma D) Half the width of the stoma

C) The widest part of the stoma The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.

An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? A. Keep a food diary to determine the foods that exacerbate the client's symptoms. B. Provide the client with a bland, low-residue diet. C. Toilet the client on a frequent, scheduled basis. D. Liaise with the primary provider to obtain an order for loperamide

C. Toilet the client on a frequent, scheduled basis. Rationale: Because the client's fecal incontinence is most likely attributable to cognitive decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this client's health problem.

A clinic nurse is caring for a male client diagnosed with gonorrhea who has been prescribed ceftriaxone and doxycycline. The client asks why he is receiving two antibiotics. What is the nurse's best response? A. "There are many drug-resistant strains of gonorrhea, so more than one antibiotic may be required for successful treatment." B. "The combination of these two antibiotics reduces the later risk of reinfection." C. "Many people infected with gonorrhea are infected with chlamydia as well." D. "This combination of medications will eradicate the infection twice as fast than a single antibiotic."

C. "Many people infected with gonorrhea are infected with chlamydia as well."

A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A. Ensure that the client knows that he or she will be responsible for care after discharge. B. Reassure the client that many people are fearful after the creation of an ostomy. C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. D. Arrange for the client to be seen by a social worker or spiritual advisor.

C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. Rationale: If the client is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the client and explore the factors that underlie it. It is presumptive to assume that the client's behavior is motivated by fear. Assessment must precede referrals and emphasizing the client's responsibilities may or may not motivate the client.

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

C. An absence of blood in stool Rationale: Bloody stool is far more common in cases of UC than in Crohn disease. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn) and clients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohn disease often has a more prolonged and variable course.

A nurse is preparing to administer a client's scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform which action with used needles? A. For multiple injections, insert the needle into the bed. B. Recap the needle immediately before leaving the room. C. Avoid recapping the needle before disposing of it. D. Wear gloves when administering the injection.

C. Avoid recapping the needle before disposing of it.

The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action? A. Covering open wounds at all times B. Vigilant handwashing in home and work settings C. Consistent use of mosquito repellents D. Annual vaccination

C. Consistent use of mosquito repellents

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.

C. Consume high-residue, high-fiber foods. Rationale: Goals for the client include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded

A client's diagnostic testing revealed that the client is colonized with vancomycin-resistant enterococcus (VRE). What change in the client's health status could precipitate an infection? A. Use of a narrow-spectrum antibiotic B. Treatment of a concurrent infection using vancomycin C. Development of a skin break D. Persistent contact of the bacteria with skin surfaces

C. Development of a skin break

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity

C. Document that the stoma appears healthy and well perfused. Rationale: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.

A parent brings the client's 12-month-old child to the clinic for a measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the parent about the MMR vaccine? A. Photophobia and hives might occur. B. There are no documented reactions to an MMR. C. Fever and hypersensitivity reaction might occur. D. Hypothermia might occur.

C. Fever and hypersensitivity reaction might occur.

The nurse is providing care for an older adult client who has developed signs and symptoms of Calicivirus (Norovirus). What assessment should the nurse prioritize when planning this client's care? A. Respiratory status B. Pain C. Fluid intake and output D. Deep tendon reflexes and neurological status

C. Fluid intake and output

A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A minimum of 30 g of soluble fiber daily B. Increased intake of free water and clear juices C. High intake of strained fruits and vegetables D. A high-calorie, high-residue diet

C. High intake of strained fruits and vegetables. Rationale: A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are given. These foods are important sources of vitamins A and C. Adequate fluid intake is important, but it does not need to be particularly high. High fiber intake would lead to complications.

A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications? A. 5% deficit in body weight compared to pre-illness weight and increased caloric need B. Calorie deficit and muscle wasting combined with low electrolyte levels C. Inability to take in adequate oral food or fluids within 7 days D. Significant risk of aspiration coupled with decreased level of consciousness

C. Inability to take in adequate oral food or fluids within 7 days. Rationale: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parentera

A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The client should be assured that this is a normal, age-related physiologic change. C. The client's polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.

C. The client's polyps constitute a risk factor for cancer. Rationale: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.

A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional support D. The family's ability to manage the client's medication regimen

C. The family's ability to provide emotional support. Rationale: Emotional support from the family is key to the client's coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the client's health status. It is highly beneficial if the family is willing and able to accommodate the client's dietary needs, but emotional support is paramount and cannot be solely provided by the client alone.

A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patients high risk for urinary retention and should implement what intervention in the patients plan of care? A) Relaxation techniques B) Sodium restriction C) Lower abdominal massage D) Double voiding

D) Double voiding To enhance emptying of a flaccid bladder, the patient may be taught to double void. After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective.

An adult patient has been hospitalized with pyelonephritis. The nurses review of the patients intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? A) Supplement the patients fluid intake with a high-calorie diet. B) Emphasize the need to limit intake to 2 L of fluid daily. C) Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. D) Encourage the patient to continue this pattern of fluid intake.

D) Encourage the patient to continue this pattern of fluid intake. Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. No need to supplement this fluid intake with additional calories or sodium.

A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding? A) Use a slipper bedpan. B) Apply a cold compress to the perineum. C) Have the patient lie in a supine position. D) Provide privacy for the patient

D) Provide privacy for the patient Nursing measures to encourage normal voiding patterns include providing privacy, ensuring an environment and body position conducive to voiding, and assisting the patient with the use of the bathroom or bedside commode, rather than a bedpan, to provide a more natural setting for voiding. Most people find supine positioning not conducive to voiding.

A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurses most appropriate response? A) Report this finding promptly to the primary care provider. B) Obtain a sterile urine sample and send it for culture. C) Obtain a urine sample and check it for pH. D) Reassure the patient that this is an expected phenomenon.

D) Reassure the patient that this is an expected phenomenon. Because mucous membrane is used in forming the conduit, the patient may excrete a large amount of mucus mixed with urine. This causes anxiety in many patients. To help relieve this anxiety, the nurse reassures the patient that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required.

A nurses colleague has applied an incontinence pad to an older adult patient who has experienced occasional episodes of functional incontinence. What principle should guide the nurses management of urinary incontinence in older adults? A) Diuretics should be promptly discontinued when an older adult experiences incontinence. B) Restricting fluid intake is recommended for older adults experiencing incontinence. C) Urinary catheterization is a first-line treatment for incontinence in older adults with incontinence. D) Urinary incontinence is not considered a normal consequence of aging.

D) Urinary incontinence is not considered a normal consequence of aging. Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. Diuretics cannot always be safely discontinued. Fluid restriction and catheterization are not considered to be safe, first-line interventions for the treatment of incontinence.

A female patients most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurses data analysis should be informed by what principle? A) Most UTIs in female patients are caused by viruses and do not cause obvious symptoms. B) A diagnosis of bacteriuria requires three consecutive positive results. C) Urine contains varying levels of healthy bacterial flora. D) Urine samples are frequently contaminated by bacteria normally present in the urethral area.

D) Urine samples are frequently contaminated by bacteria normally present in the urethral area. Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/mL of clean-catch, midstream urine is the measure that distinguishes true bacteriuria from contamination. A diagnosis does not require three consecutive positive results and urine does not contain a normal flora in the absence of a UTI. Most UTIs have a bacterial etiology.

The nurse receives a phone call from a clinic client who experienced fever and slight dyspnea several hours after receiving the pneumococcus vaccine one day earlier. What is the nurse's most appropriate action? A. Instruct the client to call 911. B. Inform the client that this is an expected response to vaccination. C. Encourage the client to take NSAIDs until symptoms are relieved. D. Ensure that the adverse reaction is reported.

D. Ensure that the adverse reaction is reported.

A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A. Annual screening colonoscopies B. Adherence to recommended immunization schedules C. Regular blood pressure monitoring D. Frequent screening for osteoporosis

D. Frequent screening for osteoporosis. Rationale: Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosis related to malabsorption of calcium. Lactose intolerance does not create an increased need for screening for colorectal cancer, immunizations, or blood pressure monitoring

Which of the following is the most plausible nursing diagnosis for a client whose treatment for colon cancer has necessitated a colostomy? A. Risk for unstable blood glucose due to changes in digestion and absorption B. Unilateral neglect related to decreased physical mobility C. Risk for excess fluid volume related to dietary changes and changes in absorption D. Ineffective sexuality patterns related to changes in self-concept

D. Ineffective sexuality patterns related to changes in self-concept. Rationale: The presence of an ostomy frequently has an effect on sexuality; this should be addressed thoughtfully in nursing care. None of the other listed diagnoses reflects the physiologic changes that result from colorectal surgery.

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy. B. Provide the client with educational materials that match the client's learning style. C. Encourage the client to write down these concerns and questions to bring forward to the surgeon. D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse. Rationale: A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the client's psychosocial and learning needs. Reassurance does not address the client's questions, and education may or may not alleviate anxiety.

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

D. Maintaining fluid and electrolyte balance. Rationale: All of the listed focuses of care are important for the client with a small bowel obstruction. However, the client's risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent

D. The risk of becoming laxative-dependent. Rationale: Laxatives should not normally be used on an ongoing basis because of the risk of dependence. In most cases they have a minimal effect on electrolyte levels. A client who has increased activity and improved diet likely has an understanding of the usual causes of constipation. Excessive laxative use could lead to diarrhea or fecal incontinence, but for most clients the risk of dependence is more significant.

An older adult client has been diagnosed with Legionella infection. When planning this client's care, the nurse should prioritize which of the following nursing actions? A. Monitoring for evidence of skin breakdown B. Emotional support and promotion of coping C. Assessment for signs of internal hemorrhage D. Vigilant monitoring of respiratory status

D. Vigilant monitoring of respiratory status

The nurse is preparing to administer ondansetron to an older adult client. Which safety warning(s) should the nurse consider when administering the medication? Select all that apply. Do not use if the client has a heart block or prolonged QT interval. It increases sedation if used with opiates. Emphasize prevention. The client must take consistently to prevent nausea and vomiting. Explain that it must be started before travel to be effective. Explain that there is a risk for dehydration.

Do not use if the client has a heart block or prolonged QT interval. It increases sedation if used with opiates. Emphasize prevention. The client must take consistently to prevent nausea and vomiting. Not using the medication if the client has a heart block or prolonged QT interval, the fact that the medication increases sedation if used with opiates, and emphasizing prevention (the client must take the medication consistently to prevent nausea and vomiting) are all safety warnings that the nurse should consider when administering ondansetron. Ondansetron is not given to relieve motion sickness; therefore, beginning the medication before travel is not applicable. Prochlorperazine, not ondansetron, may increase dehydration in older adults.

Clients with Type O blood are at higher risk for which of the following GI disorders? Gastric cancer Duodenal ulcers Esophageal varices Diverticulitis

Duodenal ulcers Familial tendency also may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. Blood type is not a predisposing factor for gastric cancer, esophageal varices, and diverticulitis. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1271

The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client? Drink a minimum of 12 ounces of fluid with each meal. Eat several small meals daily spaced at equal intervals. Choose foods that are high in simple carbohydrates. Sit upright when eating and for 30 minutes afterward.

Eat several small meals daily spaced at equal intervals. Explanation: The client with dumping syndrome should consume small meals at intervals to reduce symptoms. The client should not consume fluids with meals. Carbohydrates should be limited and sitting upright does not relieve the symptoms. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279

A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist? Barium study of the upper gastrointestinal tract Endoscopy Gastric secretion study Stool antigen test

Endoscopy Explanation: Barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that, because of their size or location, are not evident on x-ray studies. Less invasive diagnostic measures for detecting H. pylori include serologic testing for antibodies against the H. pylori antigen, stool antigen test, and urea breath test. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272

The nurse knows the mortality rate is high in lung cancer clients due to which factor? Increase in women smokers Increased incidence among the elderly Few early symptoms Increased exposure to industrial pollutants

Few early symptoms

The nurse is cautiously assessing a client admitted with peptic ulcer disease because the most common complication that occurs in 10% to 20% of clients is: Hemorrhage Intractable ulcer Perforation Pyloric obstruction

Hemorrhage Explanation: Hemorrhage, the most common complication, occurs in 10% to 20% of clients with peptic ulcers. Bleeding may be manifested by hematemesis or melena. Perforation is erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Intractable ulcer refers to one that is hard to treat, relieve, or cure. Pyloric obstruction, also called gastric outlet obstruction (GOO), occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1276

The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client? How to milk the chest tubing How to splint the incision when coughing How to take prophylactic antibiotics correctly How to manage the need for fluid restriction

How to splint the incision when coughing

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hypotension, hyperoxemia, and hypercapnia Hypercapnia, hypoventilation, and hypoxemia Hyperoxemia, hypocapnia, and hyperventilation

Hypercapnia, hypoventilation, and hypoxemia

A client diagnosed with a peptic ulcer says, "Now I have something else I have to worry about." Which actions will the nurse take to help reduce the client's anxiety? Select all that apply. Interact with the client in a relaxed manner. Help identify the client's current stressors. Discuss potential coping techniques with the client. Offer information about relaxation methods. Inform the client the medication will solve the problem.

Interact with the client in a relaxed manner. Help identify the client's current stressors. Discuss potential coping techniques with the client. Offer information about relaxation methods. A client with a peptic ulcer may have a problem with anxiety. To help reduce the client's anxiety, the nurse should interact with the client in a relaxed manner and help the client identify stressors. The nurse can also discuss potential coping techniques and offer information about relaxation methods. Stating that medication will solve the problem may not be sufficient if stress and anxiety are contributors to the development of the ulcer. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1276

The nurse visits the home of a client recovering from acute gastritis. Which observation indicates that teaching about the disorder was effective? Medications placed in a pillbox Extinguished cigarettes in an ashtray Tomato sauce simmering on the stove Cup of caffeinated coffee on the kitchen table

Medications placed in a pillbox Explanation: The client with acute gastritis should be instructed on methods of keeping track of medications such as placing the doses into a pillbox. The client should also be instructed about foods and substances that may cause gastritis, including nicotine, spicy seasoned foods, and caffeine. Cigarettes in the ashtray, tomato sauce, and caffeinated coffee indicate that additional teaching is required. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1270

A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply. Famotidine Lansoprazole Cimetidine Esomeprazole Nizatidine

Nizatidine Famotidine Cimetidine H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton-pump inhibitors. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? Notify the health care provider. Reposition the tube. Irrigate the tube. Increase the suction level.

Notify the health care provider. Explanation: The nurse should notify the health care provider because an NG tube that fails to drain during the postoperative period may be clogged, which could increase pressure on the suture site because fluid isn't draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278

During a home visit the nurse notes that a client recovering from peptic ulcer disease is experiencing cool clammy skin and has a heart rate of 96 beats a minute. Which action will the nurse take? Notify the primary health care provider. Provide a dose of a proton pump inhibitor. Encourage the client to drink a warm beverage. Discuss the types of foods the client has been eating.

Notify the primary health care provider. Explanation: The client with peptic ulcer disease is demonstrating signs of hemorrhage which include cool skin and tachycardia. The health care provider should be immediately notified. The client should not be given any additional medication. A warm beverage could enhance bleeding. It is inappropriate to provide any teaching while the client is experiencing an acute condition. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1277

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer. Nizatidine Famotidine Omeprazole Cimetidine

Omeprazole Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.

Which of the following is the most successful treatment for gastric cancer? Removal of the tumor Chemotherapy Radiation Palliation

Removal of the tumor There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278

A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal? Slows gastric emptying Provides much needed rest Allows for better absorption of vitamin B12 Removes tension on internal suture line

Slows gastric emptying Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Take the medication 2 hours before or after other medications Blood levels will be evaluated after 1 week Take the medication at bedtime to accommodate sedative effects Ensure adequate potassium intake during therapy

Take the medication 2 hours before or after other medications Explanation: Sucralfate should be taken at least 2 hours before or after other medications. It does not decrease potassium levels and laboratory follow up is unnecessary. Sucralfate does not cause sedation. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect? Vasomotor symptoms associated with dumping syndrome Dehiscence of the surgical wound Peritonitis A normal reaction to surgery

Vasomotor symptoms associated with dumping syndrome Explanation: Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, board-like abdomen, tenderness, and fever. The client's signs and symptoms aren't a normal reaction to surgery. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: restrict fluid intake to 1 qt (1,000 ml)/day. drink liquids only with meals. don't drink liquids 2 hours before meals. drink liquids only between meals.

drink liquids only between meals. Explanation: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278

12. When assessing a patient with myasthenia gravis, the nurse would be correct in questioning the patient regarding which of the following clinical manifestations? A) Weakness associated with fatigue B) Headache that worsens at night C) Projectile vomiting without nausea D) Diaphoresis

Ans: A Feedback: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Generalized weakness affects all the extremities and the intercostal muscles, resulting in varying decreasing vital capacity and respiratory failure. The other manifestations listed are not symptomatic of myasthenia gravis.

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Acute respiratory distress syndrome Lung cancer Bronchitis Tracheobronchitis

Acute respiratory distress syndrome

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis

Acute respiratory distress syndrome

Which of the following nursing interventions would be included in the care plan for a patient admitted with MS? A) Encourage the patient to void 1 hour after drinking. B) Order a low-residue diet. C) Provide total assistance as needed with all activities of daily living. D) Instruct the patient on daily muscle stretching.

Ans: D Feedback: A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? Administering oxygen, coughing, breathing deeply, and maintaining bed rest Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Administering pain medications, frequent repositioning, and limiting fluid intake

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) increase the dose of muscle relaxants. b) take a hot bath. c) rest in an air-conditioned room. d) avoid naps during the day.

C) rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Surgery to remove the tonsils and adenoids Medications to assist the patient with sleep at night Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BiPAP)

Continuous positive airway pressure (CPAP)

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Respiratory acidosis

D) Respiratory acidosis Explanation: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake. Offer nutritious snacks 2 times a day.

Encourage increased fluid intake.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hypotension, hyperoxemia, and hypercapnia Hyperventilation, hypertension, and hypocapnia Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation, and hypoxemia

Hypercapnia, hypoventilation, and hypoxemia